This paper was published in The Journal of Optometric Vision Development. Voloume 34 Number 1, Spring 2003, pages 24 to 30.

Nearsightedness:
Seeing Beyond The Obvious - Part 1 by Roberto M. Kaplan
Key Words: nearsightedness, myopia, lenses, vision therapy. INTRODUCTION Visual science attempts to explain the development of nearsightedness by examining the components of the physical eye. (1 - 5) Using rational thinking, theories about the causes and treatments of nearsightedness have evolved. Many clinicians have accepted these research conclusions as obvious facts. For example, when the various optical components interact resulting in an out-of-focus image on the retina, the eye is described as myopic or nearsighted. The person has an out of focus eye when looking into their distant world. The facts state that an obvious rational treatment for an out-of-focus eye is to diverge the light rays with a minus lens. Like a medication that soothes away a headache, a minus lens gives instant gratification - the blurred view of the distant world comes into illusionary focus for the person. It is therefore no surprise that minus lenses many years ago became the treatment of choice for nearsighted patients. For a person with a busy doing life spectacles or contact minus lenses are the prefect quick solution for becoming focused outside of oneself. Gallop says, and many vision therapy oriented clinicians would agree, that Optometry seems addicted to 20/20 distance acuity. This obsession with 20/20 acuity has created acuity addicts. (6) The difficulty many clinicians have been faced with is that the wearing of minus lenses doesnt permanently alter the optics of the eye. If the

minus lens were a corrective therapy then wearing the minus lens would result in a lowering of the measurable nearsightedness. This is not the case. The minus lens compensates for out of focus optics, however, when the minus lens is removed the eye optics are still out of focus, and the person again sees unclear. Clinical evidence shows that education and the wearing of minus lenses increases the nearsighted optical measurements of the eye resulting in further drops in visual acuity of the patient. In 383 school children from ages 6 to 17 years, the prevalence of myopia increased from 30% at ages 6-7 years, to 70% at ages 16-17 years. (7) It is the purpose of this paper to look beyond the obvious logical explanations of nearsightedness. Seeing beyond the physical eye into the not-so-obvious provides a deeper look into the the actual causes of nearsightedness in a physical eye. To accomplish this means going into the brain and mind of the person who has a nearsighted eye. Behind the eye lies the not-so-obvious with answers to how clinicians and patients alike can more effectively manage nearsightedness and myopic behaviour. By integrating the obvious with the not-so-obvious one can propose a way to solve this clinical dilemma of alarming increases in world nearsightedness. Vision therapy can greatly contribute to what appears to be a visual condition reaching epidemic proportions. Over 25% of the U.S. population are nearsighted, while in far eastern countries such as Taiwan, Singapore and Hong Kong, 90 per cent of young people are near-sighted. (8) THE OBVIOUS - WHAT WE THINK WE KNOW Clinicians measuring refractive errors keeps themselves focused on the physical reality of the eye. The measurement of nearsightedness is an eye finding based on an out-of-focus image on the retina. A primary care approach is to treat the eye problem alone and solve the patients symptom of blurred distance vision by using minus lenses. These days clinicians can be seduced to believe that corrective laser surgery is an answer for the problem of a nearsighted eye as well.

There are many theories regarding the etiology of nearsightedness which in turn have led to many contradictory methods of treatment and therapy. Research from Asia emphasises environmental factors, like close work. In Europe genetics is considered more. Studies using bifocals to reduce accommodative demands have had varying results. (9 and 10) The role of academic demands seems to be a major factor in the progression of nearsightedness. (11) If the person looks through their full nearsighted lenses for close work it is proposed that this will lead to the eye ball elongating resulting in the distant eyesight decreasing. A recent study, reported in New Scientist, November 20th, 2002, used under prescribing as a way to control the increase in nearsightedness. 47 children with under corrected nearsightedness deteriorated more rapidly than those given full prescriptions. Yet, when Asian children wore progressive lenses with between +1.5 and 2.00 diopter adds the progression of nearsightedness lessened as the adds increased. (12) Gallop reminds us that from a deeper point of view, it is the eye that is nearsighted whereas it is the behaviour of the person that is myopic. (6) He proposes that what we measure in the eye should be called nearsightedness. Behavioural optometry has built a strong case for nearsightedness in the eye being orchestrated by the conditioning of the human being behind the eye. Gallop suggests that this control mechanism for the nearsighted eye be called myopia. It is the myopic behaviour of the person that leads to the development of a nearsighted eye. This discernment between what happens in the eye (nearsightedness-theobvious) and behind the eye (myopia-not-soobvious) is a good starting place for this paper. CLINICAL OBSERVATIONS - GLIMPSES OF THE NOT-SOOBVIOUS In my practise of vision care, my time has been divided into two phases. Firstly, as a clinician, I spent many hours of the day conducting vision examinations to determine and refine lens prescriptions for nearsighted

patients. I noticed in the early years of my career, my thinking was much more oriented to the obvious approach in treating nearsightedness. I would instruct my patients to wear their full minus and stated there was nothing that could be done to correct the problem of an out-of-focus eye. As my interest in vision therapy deepened I began to change the way I spoke to my nearsighted patients. Through vision therapy it became apparent that myopic behaviour could be modified by modelling what farsighted individuals have mastered well, that is, how to see into the future, project their seeing ahead. In the not-so-obvious behind the eye, in the brain and the mind was information that could help me guide the patient to change their myopic behaviour. (13) Interacting with a nearsighted person usually reveals linear and rational behaviour. A forward directed stooped posture is possible. A myopic tendency is to ask many logical questions. Persons with nearsightedness tend to pursue learning, reading and close activities . Farsightedness persons tend to be more spatial than temporal, and reach out into their world by participating in outdoor activities in preference to reading. In my observations, these varying ways near and farsighted individuals direct their eyes from the mind seemed like different personality states. Psychiatrist Putman evaluated brain wave patterns of visually evoked responses in 10 patients with multiple personality disorders. (MPD) His examination took each patient through three personalities. He identified startling differences, where the subjects seemed to vary as much from one personality to another as from one normal person to another. (14) Optometric findings were taken on MPD patients in their various personalities. One patient needed a correction for nearsightedness nearly four times stronger for one personality than another. When the subject changed into a 6 year old, her nearsightedness improved to the point that her original childhood prescription adequately compensated her visual acuity back to 20/20. In her teenage personality this patient required an increase in prescription strength, but her unaided visual acuity was better than her adult selves.

It would appear that the brain and the mind go through profound measurable changes as these MPDs change their personalities. This suggests that their is a vast capacity for human beings to reorganise their inner worlds. Surely, this reorganising phenomenon could be applied to myopic behaviour and nearsighted seeing. INTEGRATED VISION THERAPY Integrating the obvious with the not-so-obvious led me to write about an integrated form of vision therapy.(15) I learned that modifying lenses before the patients eyes, with the intention of encouraging greater degrees of binocularity demanded of them to restructure their perceptions. Rather than just trying to bring their acuity into focus I used lenses to train a deeper integrated awareness in the brain and mind. This helped patients to have new perceptions, thus providing them with a way to modify their myopic behaviour. I observed that the success of changing myopic behaviour would result in immediate visual acuity changes. (16) With practise these new perceptions eventually programmed the nearsighted eye and less diopters would be recorded. (17) These changes in patients demanded of me to examine my usual full strength minus lenses I was prescribing. During vision therapy I encouraged deeper and deeper spatial viewing for these nearsighted patients. At home they had specific practices to follow using sometimes two or three spectacle lenses of different dioptric strengths. I made sure that patients were informed that for driving they were to use full-strength lens prescriptions. Reduced lens prescriptions were a form of home integrated vision therapy. (15) (The lens prescribing strategies will be the topic in part two of this paper) Using my retinoscope I shifted from just measuring the obvious nearsighted optics in the eye. I followed the principles of behavioural optometry and investigated the retinal reflex while engaging the patient in the not-so-obvious. For example, I saved some of my case history

questions to be asked during retinoscopy. I wanted see what would happen to the retinal reflex when I engaged the human being behind the eye. The favourite question was: When did you first receive eyeglasses? In this not-so-obvious approach to retinoscopy I am less interested in the retinal reflex informing me about the refractive status. As the patient goes through their thinking and remembering process, one is observing the changes in the colour of the reflex and movement. When the patient accesses unclear states of their personality in their mind, they will usually not feel comfortable. The patient can remember situations which are linked to their inner decision to alter the perception of their outer world. These not-so-obvious inner processes are reflected in the eye via the retinal reflex. Like a new language, one can learn to interpret the colour and reflex changes to see when the patient retreats further into their myopic self or reaches out in a farsighted way. In other words, retinoscopy can be used to observe how and when the patient learns from vision therapy to make the inner mind changes of being less myopic and moving in the direction of hyperopic behaviour. A second and profound way to interpret the inner workings of the visual behaviour of the patient is to interpret the genetic and imprinting conditioning of perceptions from the iris of the eye. (This strategy will be the topic in part three of this paper) COMPUTER ANALOGY TO EXPLAIN THE NOT-SOOBVIOUS The changes in the inner world of the patient demanded a new way of explaining what was happening in the nearsighted eye. I would explain to my patients that the eye can be considered like a scanner or fax machine. In the scanner part of the analogy, the eye receives light and like a scanner transforms this raw information into electrical impulses that are transmitted to the brain. In the fax analogy, the eye is able to print out messages from the brain of the patient. In the obviousapproach to treating nearsightedness a minus lens can focus the light more accurately. However, the over focusing minus lens can program the not-so-obvious in a way that leads to further myopic

development. The more the patient becomes addicted to the minus lens in their mind the greater the likelihood the fax in the eye will say give me more. Clinical experience and research shows that over time the fax keeps printing out the need for stronger minus lenses. In other words, the application of full as well as under corrected minus, without a program of integrated vision therapy, is insufficient in altering myopic behaviour. The analogy can be extended to the brain and the mind as well. The scanner brings in a replica of an image into a computer. The brain, like the scanner stores the raw data of what is transmitted through the eye. With the appropriate software of the mind, which in vision therapy we call developmental experience, the person is able to interpret the image scanned in. The perceptual state of the patient will determine how this scanned image is viewed and understood. If the patients inner personality is one of myopic behaviour then the message that is sent as a fax to the eye is seen via the retinal retinoscopic reflex as a nearsighted eye. The subjective visual acuity response is that the patient sees less. The retinoscopy reveals a dimmer reflex because the patient is less engaged in reaching out to their visual world. It is safer for them to remain in their inner myopic world. Integrated vision therapy offers the patient a way to be guided in changing this myopic personality behaviour. Through experience they master how to modify their perceptions and find safe ways to reach out once again in a more farsighted way. These developmental changes can be measured via retinoscopy, subjective findings, binocularity and visual acuity. (17) In order to be able to read the fax messages in the eye it is useful to further understand the scanning process of the analogy. Scanners can be adjusted to scan in material in varying degrees of clearness and precision. By changing the dots per inch setting modifies the final image that is stored in the computer. In a similar way, the physical eye is designed to receive light in two ways. Incoming light can be focused onto the fovea or peripherally

scattered onto the retina. Foveal directed light results in an image that has higher resolution than retinal processed light. Harris suggests that vision can be considered like adjusting bandwidths. (18) The bandwidth determines how much information is simultaneously transferred through the visual system. A wider bandwidth is when a large amount of information is being transported. In the case of the visual system this would be the retinal component where decisions can be made based on lots of information being received at the same time. A narrow bandwidth occurs when only a portion of the capability of the system is in use at one time. There is less data available for the person to make a decision about what is seen. The narrow bandwidth would be akin to a foveal way of perceiving, like reading a sign while driving. The view of the world is narrowed down to have only the relevant information necessary to understand what is looked at. CONSTRUCTING OUR VIEW OF REALITY This bandwidth design principle of the eye must be considered if we are going to have an impact on helping the patient modify their myopic behaviour software. In the obvious approach to vision care the tendency is to limit our treatment options to full compensating minus lenses for the treatment of nearsightedness. What is important for the patient in this approach is to get the light rays focused on the fovea. In this case the light scanning process through the fovea programs the mind to enter into more thinking and understanding. Be clear, think, and be precise. This is helpful in small dosages because foveal directed light helps the person construct their mental identity, the understanding part of their personality. This helps the who do I think I am part of their inner visual construct. On the other hand, a full compensating minus lens prescription forces the person to construct a perceptual reality that who they are is who they think or understand they are. This thought driven myopic behaviour of the patient is further cemented in its development by over focused minus lens light through the fovea. The myopic behaviour is

characterised by the patient having the tendency to explain and rationalise their feelings and perceptions. Nearsightedness compensated with a full minus lens creates a frozen state of existing, where the person is driven to look to understand. What in turn is suppressed is the ability for the person to see and feel - to know who they really are and how to have a deeper interpretation of their life. When the person trains themselves to suppress or not see parts of their visual reality, this leads to a distancing from significant aspects of their environment, emotionally, and physically. There are distortions in how the outside world is seen as well as how the self is perceived, states Orfield. (19) By reducing the minus lens and defocusing foveal light leads the patient to appreciate the less focused retinal light - in Harriss terms, a wider bandwidth. This programming of the scanner sets the stage for the patient in their mind to look and do less and see and feel more. This means they learn to rely more on feeling what they are looking at thus perceiving less from their analytical looking. In the long run this activates less myopic and more movement toward hyperopic behaviour. The patient can then discern what their true nature is versus their conditioned personality. Is it possible that myopic behaviour is part of a conditioning process that takes the person away from being their true self? By reducing the compensating lens prescription we are assisting the patient in realising what their conditioned behaviour is. In addition, the integrated vision therapy practices of expanding perception, to include retinal feeling, guides the patient out of their survival foveal looking. TYPES OF NEARSIGHTED PATIENTS From my clinical experience three kinds of myopic patients have been identified: i) Logical thinker This person is more entrenched in their myopic behaviour.They are very

fast in their thinking and talking. They tend to have their own answers well constructed from mental reasoning and are fixed in the way they want to handle their vision care. These persons will more than likely follow conventional vision care desiring maximum visual acuity and will not have time to talk about options like not-so-obvious, except perhaps corrective surgery, because they have read about it. From my experience, it is best to treat these patients in the normal way with full minus prescriptions. However, I examine the subtle levels of binocular vision. I demonstrate these breakdowns of binocularity with the full minus lenses in place to the patient to illustrate that there is more to vision than just visual acuity, diopters and sharp eye sight. This is a preparation for when the logical thinker one day in the future shifts their perceptual attitude to level of the fitness thinker. ii) Fitness thinker The fitness thinker has had an internal experience where they recognise that they have control over how their body functions and behaves. These patients have modified their lifestyle and are better taking care of themselves. They read books on topics of health and fitness. They exercise more regularly and eat healthier food. The patient may ask whether there is anything they can do for their eyes. Are there exercises I can do to help my eyes? The fitness thinker is an excellent candidate for deeper visual examination of their binocular system. In most cases a reduced lens prescription can be prescribed in addition to their full compensating lenses. (Reference 17) Once this patient has worn the fitness lens prescription then more than likely they will over time become a transformer, and move into level iii). iii) Transformer thinker These myopic patients have been through the spectrum of wearing eyeglasses and contact lenses and reach the point where they say they can no longer tolerate their contacts and/or their strong glasses bother them. At first glance it may appear that a simple lens modification would be the answer for this level of patient. Generally this is not the case. The transformer has involved themselves in personal development

experiences that has led to a fundamental change of what is happening in the not-so-obvious, the software of their mind. This creates a very interesting and usually frustrating clinical dilemma. The transformers visual acuity is unstable and their dioptric findings are more difficult to pin down. In a busy practise it can be easy to dismiss the transformer as a malingerer who is unable to pay attention to your instructions. I have learned to love these challenging patients. They offer me the excitement and opportunity to expand my vision of what is possible when I consider the not-so-obvious. The transformer is in a state of change. The research of visual changes in multiple personality disorders (MPD) implicate that the transformers fax of the changeable eye findings means they are in the process of modifying their software and programming in their minds. As clinicians it becomes prudent to consider lens prescriptions for the transformer that assist them in seeing in their new way. Generally, this means to reduce the minus to maximum binocularity as well as to an acuity level, usually 20/40, where the light is less focused on the fovea. This approach lets the transformer think less and see and feel more. This helps them guide their lives and transform it to match their true nature not their conditioned thinking. If the prescription is relatively equal between the eyes vision therapy for binocularity and fusion can be started. In addition, emphasis on peripheral awareness and movement can be included. Also, be prepared to set aside time to talk to the transformer. They will have lots of questions and I arrange an integrated vision therapy appointment time for these moments, especially when they begin to feel more deeply. This classification of myopic patients can help identify the best method of approaching the management and treatment options. Vision therapy oriented optometrists recognise that much of their practise involves educating patients about the positive outcomes of vision therapy. The logical thinker with gentle guidance can become a fitness thinker, and with experience and time,

become a transformer. This is a way to increase the number of nearsighted patients who are willing to undertake a corrective approach to their myopic behaviour. SUMMARY This article looks at the alarming increase in nearsightedness in persons living in countries where education is emphasised. It is clear that the obvious treatment of minus lenses does not appear to be correcting the nearsightedness in the eye. A not-so-obvious approach of integrated vision therapy is proposed to correct the myopic behaviour. The input and output system of vision is revisited in the form of a computer, scanner, facsimile and software analogy to explain the inter-relationship between the eye, brain and mind. A different analysis of the retinoscopic findings is presented as a way to have a glimpse into the deeper world of the patients myopic way of survival thinking. In addition, modified minus lens prescriptions can be considered that help the patient construct new perceptions that disembed their myopic behaviour. Three types of nearsighted patients have been identified. Varying treatment options have been outlined to alter the myopic behaviour in the patients brain and mind. Clinicians are encouraged to adopt a broader and integrated approach to vision therapy. In this way modified lens prescriptions can become a true corrective therapy. This will change the current primary care method where full prescriptions further embed myopic behaviour. It is the integration of retinal and foveal driven light that leads to a balance in the brain. Integration is necessary in order to construct a full picture of reality. Seeing beyond the obvious, is a life process that deeply transforms myopic perceptions. The patient is helped when we modify the lens prescription and guide them in changing their myopic patterns of behaviour via integrated vision therapy. Perhaps including the not-so-obvious approach with the obvious will

help alleviate the epidemic of nearsightedness so prevalent in our world today. Is it possible that to look and see in a broader and more integrated way will help in creating a peaceful way of seeing more deeply the challenges of the world. Can this depth of perceiving into self and others lead to less need for terrorism and war? REFERENCES 1. Schaeffel F. Howland HC. Properties of the feedback loops controlling eye growth and refractive state in the chicken. Vision Res. 1991 31: 717-34. 2. Troilo D. Wallman J. The regulation of eye growth and refractive state: an experimental study of emmetropization. Vision Res. 1991 31:1237-50. 3. Grosvenor T. Perrigin DM. Perrigin J. Maslovitz B. Houston Myopia Control Study: a randomized clinical trial. Part II. Final report by the patient care team. Am J Opto. Physiol Opt. (3PJ), 1987; 64 (7): 482-498 4. Zylbermann R. Landau D. Berson D. The influence of study habits on myopia in jewish teenagers . J of Ped Ophth. & Strab. 1993:30(5): 319-322 5. Gwiazda J. Bauer J. Thorn F. Held R. A dynamic relationship between myopia and blur-driven accommodation in school-aged children. Vision Res, 1995 35(9):1299-304 6. Gallop S. Whats so great about 20/20? or The plight of nearsightedely-challenged individuals. J Behav Opto. 2001 12 (2) 7. Lam C.S. Goh W.S. The incidence of refractive errors among schoolchildren in Hong Kong in relationship with the optical components. Clin Exp Optom. 1991 74:97-103 8. Lin L.K. Chen C.J. Hung P.T. and Ko L.S. National- wide survey of

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19. Orfield A. Seeing space: Undergoing brain re-programming to reduce myopia. J Behav Opto. 1994; 5 (5) __________________________________ Correspondence regarding this article should be addressed to Roberto Kaplan, OD, FCOVD, Post Office 68, Roberts Creek B.C. V0N2W0 Canada. e-mail: robertokap@sunshine.net __________________________________________________________ Common Law Copyright 2003 - 2010 Roberto M. Kaplan. - All Rights Reserved