Whats So Great About 20/20?
The plight of refractively-challenged individuals
This paper deals with myopia reduction and myopia control. It began as a presentation at the Third International Congress on Behavioral Optometry held in Washington, D.C. in 1998. It was in large part a discussion about the many aspects of the visual process involved in myopia reduction and myopia control. It was a somewhat tongue-in-cheek look at the whole issue of nearsightedness from a very different perspective. I first attempted myopia reduction on myself, before trying my ideas out on anyone else. There are many ways to see things and perhaps seeing clearly is not always the best way.
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Steve Gallop, O.D. (Published 2001; Journal of Behavioral Optometry, Vol. 12, #2)
I do a lot of work with what has become known as myopia reduction. After more than 20 years of runaway nearsightedness, I was able to reduce mine by 30% or so. I have subsequently worked with hundreds of people of all ages to prevent, control, and reverse myopic progression. Over 100 years ago, Snellen determined that it is normal to see what we now call 20/20. There is probably something about that level of resolution that is actually useful for various activities. However, it is not always necessary, nor does everybody see that way. There are many reasons why a person might not see that way. The most common reason for this is probably nearsightedness. A brief footnote here: It has become my habit to describe nearsightedness as the inability to achieve maximum distance acuity without the aid of artificial lenses, or now surgery. Myopia has come to mean something distinct; that is, a psychological/behavioral profile that includes introversion, fear, need for control, a preference for academic over athletic pursuits, and nearsightedness. A given individual may have any or all of these characteristics to varying degrees. This is merely an overview, not a definition. Nearsighted people see indistinctly, unable to see sharp borders past certain distances unless artificial compensating devices are involved.
One of my hobbies is reading about subatomic physics and those who work and play with it. While this subject would seem to have no connection to the topic of myopia, I felt like I found one. Many who work in quantum physics seem to have an openness that allows them to reach out beyond their chosen field, into areas seemingly unrelated to their life’s work. Most place importance on concepts like context, interconnection, and interaction.1
The current state of the art physics tells us that the world is not made up of discreet, distinct entities.1,2,3 Our world comprises an invisible, whirling dervish of what are sometimes referred to as wavicles, and forces. Wavicles are energy/matter dualities – an attempt to put a word to the concept that matter and energy are more than just linked, they are essentially one and the same entity, sometimes seeming to be more matter than energy, other times more energy than matter. This resulted from Einstein’s famous equation, E=mc2 which provided the insight for a better understanding of this relationship. The forces are basically invisible rules-of-the-game providing organization to the movements and relationships of these wavicles. It is also clear that even the most solid matter is mostly empty space. Anyway, I don’t wish to delve any more deeply into the actual physics of this, even if I really could. The bottom line is that according to the physics, everything basically blends into everything else in one way or another. Somehow, in my mind, this was at the bottom of this unusual way of thinking about nearsightedness.
It really started out as kind of an amusing thought. After I started putting some of these ideas on paper, I began reading a book called Fire In The Mind4 which seemed to directly address some of the ideas I had been working with. I am certain the author was not addressing any optometric issues, nearsightedness included. However, some of his ideas and particularly his choice of words rang true. I’d like to include a few quotes:
But how hard it is to appreciate that one person’s distortion can be another person’s reality, that we look at the world through different eyeglasses…p.13
Of course, an important question is to what degree the orders we observe are out in the world and to what degree they are imposed by our nervous systems, the invisible spectacles that refract everything we see. p.18
Our brains are wired to see order, but we are prisoners of our nervous systems, cursed with never knowing when we are seeing truths out there in the universe and when we are merely inventing elaborate architectures. p.21
In any of our grand creations, there may be cracks in the foundations, niches in which heresies can grow. And it is by overturning monuments that new pictures of the universe emerge, new orthodoxies whose cracks will form different patterns. Whether there is hope of converging asymptotically on something called truth depends on whether you believe, like Plato, that mathematics and natural laws exist in and of themselves on some ethereal plane, or whether you believe they are human inventions – at best, an intersection between the way the world is and the way our nervous systems happened to evolve. p. 24
In building a theory of the world, it helps if one’s vision is a little blurry. p.44
This was my admittedly bizarre thought: The world is not made up of discreet, distinct entities; therefore nearsightedness provides an opportunity to see the world more like it really is at its deepest levels, that is, without such discreet boundaries and distinct entities; maybe it is actually a superior visual mode, or at least an advantage is some way. Of course it took someone as nearsighted as myself to ask the obvious question at this point: Are myopes actually superior beings being kept at bay by a world of frightened, uptight emmetropes? I haven’t decided where those of the farsighted persuasion fit in to this grand scheme. Since the percentage of nearsighted people appears to be rapidly on the increase, it should be considered that there might be some evolutionary advantage.
Some have supposed that this advantage is related to the fact that so much of our activity is devoted to reading printed material, and now computers. There are many studies that point to a connection between the prevalence of nearsightedness and level of education.5,6,7,8,9 Not intelligence mind you, but quantity of time spent in front of written material. While it is not my place to prove or disprove the possible connection between nearsightedness and intelligence, I cannot deny the likelihood. However, it is not my feeling that the advantage to being nearsighted is involved with the need for prolonged exposure to 2-dimensional surfaces for the purpose of gathering information. The advantage may be something very different…
Who says the world is actually clear? Perhaps nearsighted people are simply favored with a special mode of perception that is more tuned in to the vast web of connectivity that binds us as one world. People, places and things more like wavicles dancing about and through each other, as opposed to pretending each of us is our own solar system or galaxy, completely separate and independent from each other and everything around us unless we decide to interact. Our culture is so intent on scrutinizing one detail after another, often taking things out of context. We have spent hundreds of years ignoring and denying the interconnectedness of all things, preferring a myopic pattern of thought/behavior that assures us that everything is separate, that we live in a black and white world. Nearsightedness permits one to see things as a blurry mass of one thing blending into another, seeing more of the grayness around us. As the borders between things become less clear, the interactions between things become more defined. Our culture does not place much value on these concepts, which seemingly have no importance in our daily lives. As we all know, this sort of blurry behavior is quickly investigated and punished by sentencing the offender to a life term of so-called corrective lenses. Of course, these lenses correct nothing, least of all the deviant refractive behavior.10 They simply serve to provide a pretense that he is, and sees, just like everyone else.
In some ways it is a matter of convenience to see the world as being made up of so many discreet, clearly distinguishable fragments. On the macroscopic level the world does appear and feel like solid, discreet pieces. It is much easier, not to mention more obvious, to experience the world as bits and pieces, especially with the pace of our culture. Current thinking implies that what was previously assumed to be a concrete, objective world cannot even be said to exist outside of the subjective act of observation.1,2,3 “In other words, the act of seeing must include the perceiver of the image. In quantum physics we have learned that the perceiver has a choice given to him by the wave-particle duality of matter. He can look at the wave, or gestalt, view of matter, or he can look at the “particle,” or detail, view of matter. What he perceives depends on how he goes about looking.”11
Over 200 years ago, in The Marriage of Heaven and Hell William Blake wrote, “ If the doors of perception were cleansed every thing would appear to man as it is, infinite. For man has closed himself up, till he sees all things thro’ chinks of his cavern.”12 In the 1950s, in The Doors of Perception, Aldous Huxley stated that our system of knowledge is not so much about gathering information as much as it is about cutting away information. We narrow down our focus to concentrate on the things we decide are important or useful, or maybe just tolerable.13 This narrowing down of desirable stimuli is an important tool for both physical and psychological survival.3 It is not however the only way of dealing with the world at large, nor is it guaranteed to be the best at all times. It is likely that this filtering process occurred randomly, and built upon itself over time. That is, the winnowing of “unimportant” aspects of the environment was not necessarily based on any particular criteria other than shielding us “from the endless flux, the seething, ceaseless commotion both outside and among our neurons, the fact that neither we nor the world are ever the same from one moment to the next.”3 (p.22). We did the best we could, not having a handy guidebook describing all the factors and all the possible consequences of our choices.
This is similar to the way we adapt in response to visually challenging situations. We do the best we can based on the available information (which is typically next to nothing without the assistance of a behavioral optometrist), to enable ourselves to function visually at a level that is sufficient to cope with the task. We undergo what are almost random fluctuations until we stumble upon something that seems to work. As we know, this often results in overall, long-term visual inefficiency that must be modified through the use of vision enhancing lenses and visual training.
I am reminded of a joke told by a visiting professor in optometry school: We learn about a wide variety of topics early on, and throughout the primary grades. As our education continues, we narrow our focus more and more, emphasizing certain areas of study as we decide what we want to do with our lives. Each level of education is aimed more precisely at a particular field of interest. So, we learn more and more about less and less. One wishes to become a specialist, learning even more about even less, until one becomes an expert, who knows absolutely everything about absolutely nothing.
In the beginner’s mind there are many possibilities. In the expert’s mind there are few. 14 p.44
The line of thought put forth by Blake, and later Huxley, among others1,3,4 shows up in current thinking:
If the quantum theorists are right, we and the classical world we live in exist because it is impossible to be so acute [in processing information]. Information-gathering-and-utilizing systems [iguses] can arise because it is possible to ignore a huge amount of detail, to engage in coarse-graining. We partition the universe into an area of interest and an environment to which we can banish excess information. And so we can make rough predictions. Iguses exist by virtue of this myopia, this inherent inability to keep track of every detail. If you know everything, you know nothing.4(p.177)
It seems likely that ancient humans were able to perceive the world around them in a very different way. Somehow they were able to figure out everything necessary to survive. There was no instruction manual. There were no interpretive signs labeling the different plants, explaining what each one did and how to make use of them. We tend to attribute their ability to understand their environment to some system of trial and error. This is a safe explanation for someone who has had no exposure to these concepts. The odds against surviving en masse through trial and error for finding food and medicines would have to be high. The ancients probably had some ability to process information differently than we typically do in our present state. They were able to perceive energy to derive meaning from their environment with some degree of certainty and safety. This might be considered a peripheral kind of awareness today, and it may have been just as important to overall survival as peripheral visual awareness is to overall visual “survival”. This helped immeasurably in their attempt to survive, not initially knowing the things we now take for granted. This helped them to determine which plants were safe to consume, which were helpful in treating illness, and which ones should be used for which conditions.15 We now synthesize many different drugs based on their knowledge of plants and the medicines they developed. This has only recently received the acknowledgment and attention it deserves.
Carlos Castenada, in his series of books about his apprenticeship under the Yaqui Indian sorcerer Don Juan Matus, was taught that animals perceive energy, for example, when hunting their prey, helping them to know which would be the easiest catch. He too learned to see in this way.16 These are the kinds of things that a higher percentage of people was able to do nearer the dawn of humanity. These tasks involve perceiving differently, perhaps seeing more deeply into things. Certain people seem able to see and work with energetic emanations, or auras. Perhaps this was quite commonplace in days gone by. As we have evolved culturally, not to mention technologically, we have determined that this is too complex and confusing to deal with on a moment by moment basis. It has also been generally considered that people who do experience these things are just a bit strange, or they are making this up to get attention. It is often difficult for us to accept that such things really exist. We have therefore reduced the amount of information with which we knowingly interact in order to make life simpler and more manageable in the moment.
As behavioral optometrists we understand that visual adaptations can be appropriate to perform our various visual tasks, at the moment. The practice of behavioral optometry is based on the fact that these same adaptations may often lead to overall, long-term visual inefficiency. Becoming nearsighted is, in most cases, a functional adaptation to a visually challenging situation. In our culture, it is a good way to survive visually speaking, to some degree. Nothing comes without a price however, and that which is compromised to this end leads to a reduction in overall visual performance.17
A good example comes from a young woman, in her early twenties who came to me for a visual evaluation, complaining of increasing nearsightedness. She was in her third year of a four year program for occupational therapy, and was also playing semi-pro tennis. Her nearsightedness had begun about two years earlier. She was in a visually demanding curriculum and as time went on she began having trouble seeing in the distance. She went for an eye exam (unaided acuity 20/50 OU) and was prescribed lenses for compound myopic astigmatism (OD -1.50 -2.00×90; OS -1.00 -0.50×70). To make a long story short, behavioral vision care made sense to her. She began visual training, wore stress relieving lenses and experienced excellent results. Early in the VT program I learned that her tennis game began suffering around the same time she started wearing glasses. Vision is more about playing tennis than staring at textbooks. That may seem unfair to say, especially in our current environment. The point is that vision is primarily about movement, cultural biases aside. In order to increase effectivity in one area of visual performance (reading), this young woman had to give up overall visual performance (tennis). Fortunately, her commitment to tennis and VT resulted in the ability to have the best of both worlds after all was said and done. Her latest findings included 20/20 OU unaided visual acuity.
Due to our habit of tuning out various aspects of perception, which relate to real components of our environment, we are creating undesirable long-term consequences around how we live and relate to our world. This concept is borne out by the current state of the environment. We continue to make use of outdated technologies that are convenient in the present moment, but extremely toxic when viewed in the context of long-range survival, and planetary health. This can also be seen as something of a random fluctuation, inventing technologies that were felt to be desirable or necessary at the time. As with the other examples, this was done without knowledge of, nor concern for long term consequences. You could say that all of these situations show a significant lack of peripheral awareness. The bottom line is that this is a type of suppression. I believe this is what Blake and Huxley were getting at. We suppress the information we either feel is unnecessary or difficult to process.
We all suppress visual information on an ongoing basis3 (p.21), because it is easier than constantly dealing with physiological diplopia. We (hopefully) become so adept at this that many of us are quite surprised when we are guided into experiencing physiological diplopia, as though for the first time, under appropriate visual training conditions. We often suppress peripheral information. Visual stress leads many people to shrink their visual environment so there is less information to contend with.17 We also learn very early, and typically very well, how to suppress thoughts and emotions with which we would rather not involve ourselves constantly, or ever. Similarly, we suppress other types of information on such a regular basis that we behave as if the fact that we suppress something means that it doesn’t exist, like a young child who covers his eyes certain that he is invisible to those around him. It is also important to realize that the act of suppression takes effort.17,18 Perhaps the amount of effort decreases as we persist in the act, but it does remain. It may take a different form, but somewhere inside we know what is really there, and what we are actively excluding or avoiding.19
The retina, a specialized extension of the brain, is responsive to a few quanta of light. This can be appreciated on a conscious level. The extra-visual effects of this event are poorly understood. The visual and extra-visual effects of light impinging on the retina at a subconscious level may not have even been questioned yet. Just because we have reached the limit of our ability to measure, we should not take comfort in thinking that we have found all there is to know. The fact that something cannot be consciously appreciated does not diminish its importance, nor its ability to influence behavior. We are intimately connected to everything around us despite our cultural/technological efforts to suppress this information. The borders between us and our environment are much blurrier that we care to acknowledge. For example, we usually think of our skin as the place where the outside world ends and we begin. It is also possible to consider it as more of an interface. The best way to maximize uptake of vitamin D is to directly expose large areas of the skin to the sun.
We need to accept the possibility that there may be more than one way to see. Perhaps some ways of seeing are appropriate for some circumstances, and other ways appropriate for other circumstances. A balance must be achieved, utilizing various aspects of the visual process in diverse ways.17(p.46) This moment accentuating one aspect, that moment another, keeping things flexible and always at the ready as demands change. It is also important to remember that there are many aspects of the visual process, of which acuity is but one. In all likelihood it is not even the most important one. We are limiting ourselves in many ways, at many points in the process of vision by attending so single-mindedly to visual acuity. It may be that visual acuity is not the beginning of the visual process, but more of an end result. We are taught that acuity is necessary to get the visual process off to a good start. My experience has shown that there is significant improvement in acuity once the entire visual process is enhanced. Once we are able to make greater use of all available visual information, of all aspects of the visual process, we see better.
What are we as optometrists doing?
The standard prescription for nearsightedness, obtained via the standard eye exam, is only truly appropriate for a stationary, standardized patient viewing stationary, standardized symbols 20 feet and beyond, under standardized lighting conditions. Since the decision to prescribe this way is based on such limited information, it is absolutely appropriate for very little of the overall needs of the typical wearer. What percentage of our time is actually spent doing the kinds of activities that truly require a prescription that is based strictly on distance acuity? For most people the kinds of activities that really require a full compensating prescription are somewhat limited. These might include night driving, driving in unfamiliar places, visiting museums, movie viewing, live performances, sporting events and perhaps TV. We can also be fairly certain that situations presenting these same demands pop up frequently throughout the average day. However, most of these are fairly short-lived situations. Naturally, many of us need to frequently shift our attention between various distances. However, for most of us, the majority of our viewing requirements are within 10-15 feet. Many of us spend significant amounts of time viewing within 1-4 feet. These are the activities that tend to persist for longer stretches of time.
For people in school environments this may get a little trickier. A good deal of information is still presented on a board at the front of the room. In these situations it may be difficult to circumvent the need for compensatory lenses that are fairly strong. Obviously there are ways around this such as special seating, bifocals or dropping out of school. A prescription that is strictly designed to compensate for longer distance viewing does not begin to address the full scope of visual needs that confront us on a regular basis. In fact, such prescriptions tend to reduce overall efficiency in the long run. The important thing is that this is not a black and white issue. Many variables must be acknowledged and considered in the final decision. There may not be an easy answer, and there may be several answers. The point is, we must improve our efforts to assure that we are asking the right questions..
Our profession seems to be addicted to 20/20 distance acuity. It’s not that I’m opposed to 20/20 acuity. I just want to be clear about how and why we get there. Actually, a large percentage of my patients can see 20/15 or better with or without lenses. They seek my care to address functional problems that are unrelated to acuity. Often, we are forcing otherwise decent people to require excessive distance acuity. Our obsession with 20/20 has created acuity addicts. This is because they believe what our profession believes: 20/20 acuity is perhaps the most important issue to be resolved during an eye exam. This is what our optometry schools teach us, and what we in turn teach the public. In my experience, some people will be impeded in their process of vision improvement if they continue to wear their standard issue, full-strength, compensating lenses. They must be freed from their restrictive lenses to be able to adequately experience other aspects of the visual process. Full-strength compensating lenses tend to deaden the system, if not the whole person.20 In some cases prescription and/or acuity reduction will only be a temporary measure. Once the overall goal has been achieved, the person can decide which lenses are optimal for their needs. They can begin to think about, and decide what level of acuity is appropriate for them, and when. In other cases there is an absolute trade-off. Maximum distance acuity cannot be had simultaneously with maximum visual comfort and efficiency. This may only be in the short term, but it may be sufficiently important to consider more routinely.
If people have become addicted to their full-strength prescription and what it “provides,” it can be difficult to incorporate a “reduced” lens as part of the enhancement process. It is almost certain that once a reduced prescription is worn for some period of time (a week or so, typically), the person will try on the old prescription and report that things do look clearer. However, they will also report that there is either a feeling of tension, or actual pain while looking through the old glasses for even a few minutes. Why would this happen? What does this say about what lenses bring about?
Some people, when confronted with the prospect of less than maximal acuity, experience concern or discomfort with the very idea. If they allow themselves to actually experience the difference for some time, while also doing training to improve overall vision, they will in most cases begin to feel more comfortable with the reduced clarity. Spending more time with a reduced prescription will typically result in improved acuity with the weaker lenses, which can lead to further lens reductions. Once an “endpoint” is reached, a decision can be made whether to stay with reduced acuity on a more regular basis, or to have maximum acuity, which will typically be achieved with less lens power than previously worn.
The standard approach to prescribing lenses, still forcefully taught in all optometric schools, is woefully outdated for several reasons. It represents a very one-size-fits-all model, treating symptoms instead of people. Just because a person is able to see clearly at all distances with certain lenses doesn’t mean that this is the optimal management. This puts undue stress on the visual system more of the time than not. We are forcing people into a perceptual mode that is culturally imposed. As with most allopathic treatments, we are creating significant, undesirable side effects. However, in this case we are completely ignoring these side-effects thereby letting them continue unabated. Most people are quite unaware that there is even a problem. However, there are many times when people leave the optometrist’s office with their new glasses complaining that they feel too strong, only to be told that they will get used to it. This usually does happen, but why don’t we try to understand what causes this and if there is a better response than just summarily dismissing this issue.
Lenses are a type of medication, even though they are not taken internally. However, the subsequent perceptual side effects are greatly internalized. There is a compression of three dimensional space and of time.10 It seems certain that people adapt and compensate for these distortions, but at what cost. Our profession has put little effort into acknowledging, let alone coming to terms with these issues. Obviously, within the context of our culture, the ability to see extremely clearly comes in very handy much of the time. Some situations make it necessary. My feeling is that it is much more important to deal with overall functional health before attending to a fairly minor, secondary condition.
The nearsighted, farsighted, or astigmatic reality is that in the uncompensated state, the person does not see clearly under certain viewing conditions. While compensating for this may be useful for socially compulsive visual demands, it is a severe intrusion on the natural state. It is common practice for someone with undesirable refractive findings to be given a full-strength compensating lenses for full time wear. This begins a downward spiral of visual performance along with what are, in most cases, negative behavioral adaptations. These changes tend to reduce the amount of available information from which one can gain meaningful input. People tend to feel that they can only get useful information from a precisely focused image. This reduces the ability to utilize the many other cues to information that are always available.
This also leads to an undesirable distancing from significant aspects of the environment emotionally, and physically. There are distortions in how the outside world is seen as well as how the self is perceived.21 A person must learn to accept who and how they are, at least to some degree. This must be done in a natural state, not under the influence of something that creates such comprehensive changes. Once there is some sense of one’s internal nature, the changes frequently seen with compensating lenses might be less disruptive, less detrimental to the individual. Optometrists should take more care and try to provide the highest level of treatment, taking the most complete information possible into account. Lenses do effect behavior. We must advance beyond the over-simplified approaches which have become the standard of care. It is our gift to be able to provide options from which an educated patient or parent can choose.
Everyone can benefit from VT. This is especially the case with those who have already begun adaptive, habitual behaviors. VT must include some type of modified prescription or wearing schedule for various task demands. A reduced prescription for near and mid-range activities can also be worn for further distances. This increases relaxation and helps modify performance if there is also some understanding of the process and its short and long term possibilities. After doing this for only a short time, especially if active training is also being done, the original prescription will typically feel too strong or uncomfortable.
I will frequently recommend +.50, or other low power plus lenses, to be worn over contact lenses, whether the contacts are a reduced prescription or not. I encourage people to wear the low plus as much as possible as long as they are not creating any unwanted stress due to their reaction to increased blur. The typical scenario is this: the person comes back after a week or so of frequent use and reports that their distance acuity is better after removing the +.50 than it was before first putting it on. This change is typically quite short in duration but easily repeatable. This implies that there is some innate ability to further relax the accommodative system as well as improve the overall processing. That is, getting more complete meaning from information that was previously felt to be of insufficient quality. The puzzling thing is that once this improved level of clarity has been accessed, it doesn’t persist for longer periods of time. Since increased clarity after brief exposure to low plus does not seem to persist, there must be some reasonable explanation. Is there some physiological limitation in reducing nearsightedness that is long standing? Is the limitation somewhere other than the physiology? Is there some advantage to a certain amount of nearsightedness that continually overrides attempts to change it?
Most changes that occur as a result of visual training, both objective and subjective, tend to remain essentially intact over time. In fact the improvement often continues as the new patterns of visual behavior insinuate themselves throughout all the aspects of integration between vision and living. My sense is that once we find a way of doing things that requires less effort, provides greater results and is more comfortable, we are likely to make certain that we access this behavior as much as possible. This, in turn, makes it likely that this learning will not be forgotten.
People need options. Most people only know what they are told, having neither the inclination, nor the time to research their situation. Optometry believes that maximum monocular distance acuity is critical, therefore the public believes this. People assume that there is only one way for lenses to work. They assume that the only issue is absolute clarity. I have found that there is often a trade-off. As previously brought out, lenses that force maximum acuity do not always provide maximum comfort. I am talking about comfort in a physical sense, a feeling of relaxation. I am not referring to the emotional comfort that comes with seeing clearly. This is a culturally imposed sensation that goes along with the artificial belief that excessive acuity is required. I say excessive acuity because 20/20 is, in many ways, a culturally imposed requirement. Some people will opt for the lenses that provide reasonable acuity and maximum comfort over the other way around. It should be their choice, not ours.
In many cases, once a person can experience different lenses, they may find that the lenses providing the sharpest acuity do not provide the greatest level of comfort and/or efficiency. They may find that they actually need a “full” prescription only for a few specific activities that only occur for short periods of time. My preference is to prescribe lenses that will provide 20/40 or so distance acuity as the primary prescription. This tends to be comfortable and effective for the majority of people for the majority of indoor visual demands. While it is certainly easier to keep just one pair of glasses and wear them constantly, when shown the options, many will choose to work with multiple prescriptions since this actually provides the greatest comfort as well as the highest level of overall performance.
A lens is a tool. It is always important to have the right tools for the job. It is possible to hammer a nail into the wall with a sledge hammer. It is possible, but not advisable. This becomes even more important if you are planning to hammer many nails into the wall. Not only are you likely to miss a few times, putting large holes in the wall, but your arm will get very tired. If you persist in this long enough, you could cause long term damage to various parts of your anatomy. Using a more appropriate, smaller hammer will enable you to pound away almost endlessly with less fatigue and greater accuracy. A concave lens designed for nothing more than excessive distance acuity is similar to the sledge hammer. While there is no doubt that such a lens will enable one to see clearly at the distance, and in most cases, at all distances, this in no way implies that it is the most appropriate tool for the job. What is the job? The job is to see comfortably and effectively at varying distances for varying periods of time, under varying environmental, emotional and physiological conditions.
The primary issue should be providing people with input, based on reasonably complete information, regarding their own healing process. When someone comes into my office with a prescription, it is because the previous doctor assured them that was what they needed. All the issues have not been discussed; all the possibilities have not been considered; all the likely consequences have not been spelled out- the potential for further deterioration, the perceptual distortions, the increased visual stress and strain. By having optometry done to them, people are acted upon by the lenses they wear. By becoming an active partner in optometric care, a person can decide how and when to use lenses to their greatest advantage. They can understand the pros and cons of what happens as they use particular lenses. They can decide if and when to have 20/20.
We have all been taught that seeing clearly is right and seeing less than clearly is wrong, some type of defect. There seems to be little question regarding this matter within optometry. We treat this as fact and we use this fact as the single and absolute goal of refraction. What if seeing blurry is actually an advantage, an evolutionary leap forward, and not something to be eradicated at all costs. It’s usually fruitful to question easy answers. Some might see this as not leaving well-enough alone, but it reduces the likelihood of complacency, and stimulates expansive thinking. “We have found it of paramount importance that in order to progress we must recognize our ignorance and leave room for doubt. Scientific knowledge is a body of statements of varying degrees of certainty-some unsure, some nearly sure, but none absolutely certain…Our freedom to doubt was born out of a struggle against authority in the early days of science. It was a very deep and strong struggle: permit us to question -to doubt- to not be sure. I think that it is important that we do not forget this struggle and thus perhaps lose what we have gained. Herein lies a responsibility to society.”22
Who says 20/20 is the optimal acuity anyway? Who decided that 20/20 was THE right way to see things every minute of every day? I’ll tell you who – a bunch of uptight emmetropes trapped in a sharply defined world of countless discreet images. These are people who have no concept what its like to see in a nice, mellow, fuzzy way, allowing the alleged borders within our environment to become less restrictive, allowing the so-called parts of the world to blend together. Why can’t we all just get along? Sometimes this way of seeing can be refreshing, if not downright enjoyable. Who among you remembers the 60s? How many of you know what it’s like to see street lights and traffic lights without all that sharpness? They look a lot more interesting when I have no lenses to distort the way I naturally see them. Of course you’d better hope that I’m in the passenger seat while I’m enjoying this uncompromised visual feast, but perhaps you get my point. Things are not always as they appear, or maybe they are but only through certain filters of perception. By limiting the filters through which we view our patients, and restricting the filters we provide for them, we are limiting the freedom to compute, perceive, and create.
1. Capra F. The Web of Life: A new scientific understanding of living systems. New York: Doubleday. 1996.
2. Bohm D. Hiley BJ. The Undivided Universe. London: Routledge. 1993.(p.176-80)
3. Darling D. Zen Physics. New York: HarperCollins. 1996.
4. Johnson G. Fire in the Mind: science, faith, and the search for order. New York: Knopf, 1995.
5. Hynes EA. Refractive changes in normal young men. Arch Ophthal, 1956,56:761- 767
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