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Lens Distress: A Young Woman’s Journey

From the Optometric Extension Program Foundation book: The Power of Lenses, Vol. 1

The Optometric Extension Program Foundation (OEP) is the oldest source for post-doctoral education worldwide.  Founded in 1938, OEP provides written materials for doctors and the public, as well as sponsoring conferences all across the world.  OEP also runs clinical curriculum courses for optometrists desiring to expand their knowledge base for those practicing, or wishing to practice with a behavioral/developmental perspective on vision care.  I was honored to be asked to contribute the following chapter to their latest publication, which was released in July 2018.

Steve Gallop, OD
Broomall, Pennsylvania

Lens Distress: A Young Woman’s Journey

Lenses change instructions and feedback to the brain. My primary interest is finding out what that brain is capable of doing before relying solely on an external device to do the work. Most lenses are compensatory in nature. They are prescribed to do something that the organism is presumably unable to do for itself. Examples are concave lenses for nearsightedness, convex lenses for accommodative esotropia, and prisms for strabismus. I prefer to try lenses (and often vision therapy) to stimulate changes in how the brain uses the visual process from the inside out. I see compensating lenses as working from the outside in, although usually there is no significant internal adjustment in response to compensating lenses other than going along with what the lenses are forcing the system to do.

Nearsightedness is becoming more and more of a concern worldwide. This is because of the dramatic increase in the incidence across the globe. It is projected that 50% of the population in the United States will be nearsighted in a generation or so. Innovations like orthokeratology, multifocal contact lenses, atropine therapy, and others are getting some results. I prefer to manage nearsightedness using lenses and/or vision therapy.

I came to the conclusion early in my career that it was unlikely that one could be nearsighted without having other binocular, accommodative, and/or oculomotor issues. Although I had a deep interest in working with nearsightedness as I entered optometry school, I quickly came to realize that the best way to prevent or to manage nearsightedness was to focus on the visual process as a whole, rather than just focusing on nearsightedness. Experience has also taught me that artificially obtained maximum distance acuity is not the best approach for everyone, especially when other visual issues remain unresolved.

I have a unique approach to managing nearsightedness. Some of what I do is based on my firsthand experience in reducing my own nearsightedness. Some of what I do is based on certain long held behavioral optometric concepts , such as keeping the prescriptions for both eyes equal whenever possible and taking care of near demands before distance needs. All in all, my approach is simply what I understand to be sound vision care from a behavioral perspective. Clinically speaking, I have had quite consistent success over the years. There are no guarantees in preventing, controlling, or reversing nearsightedness with any of the aforementioned approaches, but the result is almost always positive as regards the visual process as a whole when vision therapy and a more dynamic approach to lenses are part of the treatment protocol.

One aspect of my approach is to attempt to keep the lenses equal. This can obviously involve different acuities for the two eyes, but acuity is usually the least important issue in helping people obtain better visual performance, particularly when they are faced with more complex visual conditions. This is an old school of thought that makes sense to me. Here’s why: The visual process is pervasive in human behavior and development. I look at the visual process as a mind/body process rather than an eyeball phenomenon. I am less interested in monocular acuities—at least at first—than I am in maximizing the person’s ability to use the total visual process comfortably, efficiently, and effectively for all their daily needs. We can always deal with the acuity later in the process, usually achieving the same or better distance acuity with weaker lenses than those habitually worn at the start of vision and/or lens therapy. My experience tells me that optimal distance acuity is more likely the result of a smoothly functioning visual system, not a prerequisite for it.

Another part of my approach is to minimize or to avoid compensating cylinder whenever possible. Sometimes cylinder is unavoidable, but I will at least try to see what the minimum possible amount might be regardless of the habitual prescription, the length of time such a prescription might have been worn, or the keratometric measurements. I do not use spherical equivalents, and I do not really have a formula; each individual is treated based on their specific circumstances, needs and their desire/ability to change. I would say that the most important ingredient is to place minimal emphasis on monocular acuity and to think about how the lenses work under binocular conditions and how they will affect the visual process as a whole, and of course, the person using it. In any event, this demands a negotiation between doctor and patient—as should any lens prescription. My hope is to maximize the potential for more effective, more efficient use of the visual process. I want to challenge the system but not overwhelm it. In my experience, most compensating prescriptions are overwhelming the system in a different way. Compensating lenses often stifle flexibility in the visual system while ignoring or reinforcing various binocular, accommodative, and oculomotor deficiencies.

History

Kylie was an adopted 16-year-old at her initial evaluation. She first started wearing glasses at age six. Her glasses history is detailed in Table 1. Kylie reported that it usually “took approximately an hour to adjust to every new prescription.” Her most recent one (18 months before we met) took much longer and actually “never felt right.” She had no subjective complaints at our first encounter, reported only wearing her glasses “when necessary,” and did all close work without them. Kylie reported that her glasses made her dizzy. She came to my office from a considerable distance because her mother was concerned about Kylie’s progressing nearsightedness and was looking for a different approach to managing the situation.

Based on the fact that Kylie was not comfortable with her current lenses, as well as on the thinking that all of her old prescriptions were helping nothing other than distance acuity, I wanted to take a different approach. She was not demonstrating acceptable visual development. Binocularity was weak, near stereo acuity was poor, she showed alternating central suppression, and she had less than adequate fusional ranges. Eye movements, particularly saccades, were below expected levels and elicited an unacceptable degree of stress, as evidenced by the excessive blinking (Table 2). I knew that I would only be able to use lenses to treat her due to geographical constraints. Based on the totality of my evaluation, and my optometric instincts and clinical experiences, I decided to trial frame something that even I thought was unlikely to do very much, but was interested to investigate as a starting point. I was admittedly surprised at Kylie’s immediate reaction to the lenses I tried, which ultimately became her new prescription:

Final Rx

                 DVO OU -3.00;                    OU 20/40-2+2;       OD/OS 20/50ish

                 NVO OU -2.00;                    OU 1.0M 6-20”

Despite the reduced distance acuity, which I assumed would cause her to reject these lenses, Kylie was very happy with how the lenses felt and was not the least bit put off by the reduced clarity. The lenses were made and mailed to Kylie at home the following week. I recommended that she return for follow-up in 3-6 months.

Email correspondence from Kylie’s mom:

May 2, 2011

Dr. Gallop,

My daughter Kylie received her glasses in the mail on Saturday—and she loved them—and it put a smile on her face when she put them on. Thank you so much. Also thank you for the listing of Behavioral Optometrists in the area.

I was wondering what my daughter can do at home to help her with vision improvement. 

  

Thank you,

P

June 7, 2011

Dr. Gallop,

Just thought I would give you an update. Yesterday Kylie got a physical at the school for field hockey, and they give the normal vision testing. Well, she had on her glasses the 3 (I think) and she did very well.....she was able to see all the letters that were required. I was NOT there, so just going by what she said. 

Also, you know she seems so much happier, too. Guess it helped more than just her eyes.

Thank you,

P

June 22, 2011

Dr. Gallop,

Kylie is doing very well in her glasses and seems to be more outgoing. Never thought a pair of new glasses could do all that. 

  

When Kylie is driving (learner’s permit), the weaker glasses seem to work just great. However, she does need the stronger lens for night driving. Really wish we lived closer, but who knows, maybe in the near future we will be able to move back. 

Well, will close for now, but will update you along the way. 

Thank you,

P


August 18, 2011

Dr. Gallop,

Kylie is making out just great with her prescription. Summer has been really busy, would love to visit PA but just too hectic. 

School is starting in a few weeks and I am just so glad Kylie has the right prescription for the first time......in I don’t know how many years. You don’t know how happy this makes me. 

Will keep you posted.

September 8, 2011

Dr. Gallop,

Thought I’d share this with you. Kylie is learning to drive, well, she was driving last night in the rain.....with windows steaming up.....(I was having a hard time seeing out the window).....she was able to see very well in her glasses.

I re-evaluated Kylie one year after her initial evaluation. She had been wearing the -2.00 lenses most of the time (Table 3).

Needless to say, I was somewhat surprised that Kylie loved her new lenses, considering that her distance acuity was worse than it was with her old glasses. The fact is that she absolutely preferred less acuity and no dizziness to more acuity and constant dizziness. I have not seen Kylie for three years, but in calling to check up on her, I learned that she still uses the glasses she got from me and is now studying finance at James Madison University.

We are typically taught that maximum distance acuity is a must—anything else is simply unacceptable. I suggest that you question this thinking whenever possible. Obviously, most people (and unfortunately, most doctors) still believe that this is the main reason to get their eyes examined. I do not examine eyes. I evaluate a person’s ability to make use of the enormous potential to use the visual process to meet their daily needs. I assess their visual needs, their overall situations, and try to determine how I can best contribute to their well-being. I was surprised to learn after several years in practice that the lenses prescribed for maximum acuity are not always the best treatment decision because they do not always provide the best comfort and performance. This is because such lenses are typically derived without consideration of either the visual process or the person as a whole. Because of this, maximum acuity lenses can cause or exacerbate more problems than they solve. My main purpose in sharing this case is to stimulate thinking outside the box. Don’t stop with acuity—and don’t necessarily start with acuity.

Considering all of this, it is important to determine how the lenses, particularly compensating lenses, will influence the totality of the visual process, how the prescription will influence comfort, performance and the ongoing development of the visual process and the person.

Table 1. Glasses History

Age 11

OD: -0.75-3.75x155 OS: -0.50-4.00x015

Age 12

OD: -1.75-3.75x152 OS: -2.00-4.00x015

Age 14

OD: -2.25-3.75x155 OS: -2.25-4.00x012

Age 14-Later in the year

OD: -3.25-3.75x155 OS: -3.25-4.00x012

Current glasses (according to mother this was the first Rx from age 14)

OD: -2.50-3.75x153 20/30

OS: -2.50-4.00x015 (1BD) 20/40 20/30-2 OU

Table 2. Initial Examination Findings

K readings

OD: -3.00x165 OS: -4.50x012

Stereo

(-) GF 200” Randot

Pursuits

90% w/ excessive blinking

Saccades

80% not crisp, w/ excessive blinking 

Z-axis: inconsistent, asymmetric

Retinoscopy

Distance: -3.50-2.00 w/rule Near: -2.50 w/cyl

Maddox Rod (near; measured w/MR OD and OS)

Ortho horizontal and vertical

Prism Bar Ranges

Distance: BO x/8/6 BI 6/6 Near: BO 14/14/12 BI x/8/6

Table 3. Data from Examination One Year Later

Current Rx

OD: -2.00 20/50

OS: -2.00 20/70 OU: 20/70

K readings

OD: -3.50x163 OS: -3.62x016

Stereo

(-) GF 100” Randot; 70” Randot w/ -2.00

Pursuits

95% w/ excessive blinking

Saccades

95% mostly undershoots; no excessive blinking 

Z-axis: fairly consistent, more symmetric

Retinoscopy

Distance: -2.00-2.00x180 Near: same as distance

Maddox Rod (near; measured w/MR OD and OS)

Ortho horizontal and vertical

intermittent central suppression OS only

Prism Bar Ranges

Distance: BO x/4/4 BI 6/4 Near: BO x/10/8 BI x/8/8