Hyperopia (Farsightedness): Symptoms, Children's Eyes and Treatment

Hyperopia, also known as farsightedness or long-sightedness, is a common focusing error in which the eye has too little focusing power for its length. The name suggests that distant vision is fine and only near vision is blurry, but the reality is more interesting. Many young people with hyperopia see clearly at all distances because they compensate with their focusing muscle, often without realising it. The price can be tired eyes, headaches and difficulty concentrating on reading.

Hyperopia matters in different ways at different ages. In young children, significant hyperopia can cause a turning eye or lazy eye if it is not corrected. In adults, it often becomes noticeable in the late 30s and 40s, earlier than presbyopia would otherwise appear. Later in life, hyperopic eyes have a higher chance of a specific type of glaucoma called angle closure. This guide explains all of these points and the options for correction.

What is hyperopia?

In a normal eye, light from a distant object is focused by the cornea and lens precisely onto the retina without any effort. In a hyperopic eye, the focal point lies behind the retina when the eye is relaxed. This most often happens because the eyeball is slightly shorter than average from front to back (axial hyperopia). Less commonly, the cornea is flatter than usual or the lens has less power (refractive hyperopia). For a comparison with other focusing errors, see our overview of refractive errors.

Hyperopia is measured in dioptres with a plus sign, for example +2.00. Low hyperopia (up to about +2.00 D) is very common and often causes no problems in young people. Moderate (+2.25 to +5.00 D) and high hyperopia (above about +5.00 D) are more likely to cause symptoms and need correction.

Hyperopia is normal at birth

Almost all babies are born mildly hyperopic because their eyes are small. As the eye grows during the first years of life, hyperopia usually decreases, a process called emmetropisation. Many children still have a small amount of hyperopia at school age, which their strong focusing system handles easily. Problems arise when the hyperopia is high, unequal between the eyes, or combined with difficulty coordinating focusing and eye alignment.

Hyperopia versus presbyopia

People often confuse hyperopia and presbyopia because both cause near vision difficulty, but they are different. Hyperopia is a refractive error related to the eye's dimensions and can be present at any age, including birth. Presbyopia is the normal age-related loss of focusing ability that affects everyone from about the mid-40s. A person with hyperopia usually experiences the effects of presbyopia earlier, because they have been using some of their focusing reserve all along. Read more in our guide to presbyopia.

How the eye compensates: accommodation

To understand hyperopia, you need to understand accommodation. When we look at something close, the ciliary muscle inside the eye contracts and the lens becomes rounder, increasing its focusing power. A hyperopic person can use this same mechanism to pull a distant image forward onto the retina, and then needs to accommodate even more for near objects.

Children and young adults have a large reserve of accommodation, so they can often overcome several dioptres of hyperopia. But accommodation is muscular effort. Constant focusing, especially during long periods of reading or screen work, can cause fatigue. And as the lens gradually stiffens with age, that reserve shrinks, so hyperopia that was hidden in childhood becomes noticeable in adulthood.

Latent versus manifest hyperopia

Eye care professionals distinguish between different components of hyperopia, which explains why the prescription can seem to change with age and why eye drops are used during children's eye tests.

In practical terms, a child or young adult may read the distance chart perfectly yet still have significant hyperopia. This is why cycloplegic eye drops are standard for children's eye examinations: without them, hyperopia can be underestimated or missed entirely. It also explains why adults with hyperopia often find their glasses prescription increases gradually through their 30s and 40s, as latent hyperopia becomes manifest.

Symptoms of hyperopia

Symptoms depend on the amount of hyperopia, the person's age and the visual demands of their day:

• Blurred near vision, particularly for small print or after reading for a while
• Eye strain, aching or burning eyes after close work
• Headaches, often around the forehead or temples, typically later in the day
• Difficulty concentrating on reading, losing place, words seeming to move
• Blurred distance vision in higher hyperopia or as people get older
• Needing reading glasses earlier than friends, often before 40
• Squinting or rubbing the eyes

Headaches are a common reason people with hyperopia first come for an eye test. Not every headache is caused by the eyes, and most headaches have other causes, but correcting significant hyperopia often relieves headaches linked to reading or screen work. Our article on eye strain and headaches explains the link and how to tell the difference.

Hyperopia in children

Children rarely complain about vision. A child with hyperopia might avoid reading, have trouble concentrating, get headaches after school or appear to struggle with learning. Uncorrected moderate hyperopia has been associated in research with reduced reading skills in young children. Parents and teachers sometimes mistake these signs for behavioural or attention problems. Our article on reading difficulties and vision explains what to look for.

Accommodative esotropia

One of the most important links in children is between hyperopia and a turning eye. Accommodation is neurologically linked to convergence, the inward turning of both eyes. When a hyperopic child focuses hard to see clearly, the eyes may turn inward too much. In some children, this causes one eye to turn in, a condition called accommodative esotropia.

• It typically appears between about 1 and 4 years of age, sometimes intermittently at first, often noticed when the child is tired or looking at something close.
• Children with moderate to high hyperopia are at higher risk, as are those with a family history of squint.
• Fully correcting the hyperopia with glasses often straightens the eyes completely or largely.
• Some children need bifocal lenses if the eye still turns at near, and some need additional treatment such as patching or surgery for any remaining misalignment.

Any turning eye in a child older than a few months should be examined promptly. The guide to strabismus and amblyopia covers this in detail.

Amblyopia

If one eye is much more hyperopic than the other (anisometropia), the brain may rely on the clearer eye and stop developing vision in the blurrier one. This can happen without any visible turn, which is why vision screening matters. High hyperopia in both eyes can also cause amblyopia in both eyes. Early glasses, sometimes combined with patching or atropine penalisation of the stronger eye, give the best results, ideally before about 7 to 8 years of age, although improvement can occur later too.

Do all hyperopic children need glasses?

No. Mild hyperopia that is equal between the eyes and causes no symptoms, eye turn or amblyopia is often simply monitored, because it is normal for age and may decrease. Glasses are usually recommended when hyperopia is moderate to high for the child's age, when there is an eye turn, a significant difference between the eyes, reduced vision or symptoms such as reading difficulty or headaches. The decision is made by the optometrist or ophthalmologist based on the full examination.

Diagnosis

Hyperopia is diagnosed during a comprehensive eye examination, which typically includes:

1. Visual acuity for distance and near
2. Objective refraction with an autorefractor or retinoscope
3. Subjective refraction to fine-tune the prescription
4. Cycloplegic refraction with eye drops, especially for children and young adults with symptoms
5. Assessment of eye alignment, focusing and binocular coordination
6. Examination of the eye's health, including the front chamber depth and drainage angle in adults

Correction options

Glasses

Plus (convex) lenses add focusing power so the eye no longer needs to work as hard. Depending on age and needs, a person may wear glasses full-time, only for reading and computer work, or in bifocal or progressive form if presbyopia is also present. Strong plus lenses magnify the eyes slightly and can be thick in the centre; high-index materials and aspheric designs help. Children with accommodative esotropia usually need to wear their glasses full-time.

Contact lenses

Soft or rigid contact lenses can correct hyperopia, with toric designs for astigmatism and multifocal designs for presbyopia. They give a more natural image size than strong spectacles and a wider field of view. As with all contact lenses, good hygiene is essential to reduce the risk of infection.

Refractive surgery

Laser procedures such as LASIK and PRK can correct low to moderate hyperopia by steepening the central cornea. Results for hyperopia tend to be somewhat less predictable and stable than for myopia, and there are upper limits to how much can be treated. For higher hyperopia, especially in people over about 45 to 50, refractive lens exchange, replacing the natural lens with an artificial one, may be considered. This has the added advantage of widening the drainage angle, but it carries the risks of intraocular surgery. A specialist will advise whether you are a suitable candidate; see our guide to eye surgery options.

Hyperopia and angle-closure glaucoma

Hyperopic eyes are often smaller, with a shallower front chamber and a narrower angle where fluid drains out of the eye. With age, the natural lens thickens and can push the iris forward, narrowing the angle further. In some people, the angle can close and block drainage, causing eye pressure to rise. This is angle-closure glaucoma.

Angle closure can develop slowly and silently, or suddenly as an acute angle-closure attack, which is a medical emergency. Risk factors include hyperopia, older age, female sex, East Asian ancestry and a family history. Some medicines that dilate the pupil, including certain decongestants, antihistamines, antidepressants and drugs used for anaesthesia or bladder problems, can trigger an attack in people with narrow angles. Eye examinations can detect narrow angles, and a quick laser treatment (laser peripheral iridotomy) or cataract or lens surgery can reduce the risk. Read our full guide to glaucoma.

Can exercises cure hyperopia?

No. Hyperopia is caused by the physical dimensions and optics of the eye, which exercises cannot change. There is no good scientific evidence that eye exercises reduce hyperopia or replace glasses. Some people with hyperopia also have problems with focusing or eye coordination, such as convergence insufficiency or accommodative insufficiency, and supervised vision therapy may help those specific conditions alongside correct glasses. Relaxation techniques such as palming may make tired eyes feel more comfortable after close work, but they do not correct the underlying hyperopia.

When to see a doctor

Book an eye examination if you have frequent headaches or eye strain with reading or screen work, blurry near or distance vision, or if you need to hold things further away than before your 40s. Children should have their vision checked according to local screening programmes and sooner if a parent notices an eye turning, frequent eye rubbing, reading avoidance or a family history of squint or high glasses prescriptions. Adults with hyperopia should mention it to any doctor prescribing new medicines, and ask their optometrist whether their drainage angles are narrow.