Sometimes I say, “I don’t see very well,” but then I realize that’s not true.  I’m using those words to try to explain that things at a distance from me aren’t clear, however I am very much at ease with what I see and how I am able to interpret and interact with the world around me.  I am at ease with the way that I see; who’s to judge if it should be or could be different?
    I have worn a high prescription to improve my distance vision for almost 40 years.  Technically I am considered a myope; a highly nearsighted person.  However, I would never use those words to describe myself.  Along with the phrase, “I am a myope,” comes a shrinking of space, a dimming of my vision.  To be myopic means to be short sighted, narrow focused and rigid.  The term is used to describe how one sees and how one thinks and interacts with their surroundings.  I am not a myopic person and feel very comfortable with my vision, so why do I still feel like I need to say, “I don’t see very well”?
    We’ve been conditioned and trained to evaluate and treat refractive error without consideration for the person who’s eyes we’re evaluating and who’s brain and body we’re “adjusting” with the lenses we recommend.  There is really so much more to the process of vision than how clearly one sees.  It is often said that, “vision is more than 20/20.”  I currently wear about 4 steps less correction than a traditional eye doctor would tell me I “needed”. Is one of us “right” and the other “wrong”? Choosing the lens to place in front of a person is a far more complex decision than many realize.
    
    Recently several adult patients have been referred to me. The common answers to my initial question of, “So, what can I do for you today?” Include, “I need a higher prescription”, “My eye doctor said my prescription didn’t change, but I can’t wear these glasses”, I’ve seen everybody and no one can get my glasses prescription right”, “I can see with these glasses but it just doesn’t feel right.”
    One profile that presents often is the person wearing too much minus correction.  Many adults I see are using a few clicks more minus than is necessary to allow them to see the 20/20 letters.  My first check point is the position of their pupils as they relate to the optical center of the glasses lenses.  Most eye doctors and opticians don’t think this matters but I am convinced it’s because they have never been asked to wear several diopters of base UP prism before.  A minus lens with the optical center positioned below the pupil creates a prismatic effect that shrinks the space around you by optically moving things down and in, and causing things to appear even smaller and closer than the minus lens would all on its own. Adjusting the position of the lenses is step one but I can’t help wonder how wearing a misaligned minus lens has shifted the way the person has learned to interpret and interact with the world around them. Most of the time these patients, like myself, have been wearing corrective lenses for several decades, since they were children.  There is often a rigidity present when I make a suggestion to reduce the minus instead of giving the person a “higher prescription”, like they asked for.  I can often elicit an awareness that they can still “see” with a few clicks less minus but the insistence, that they like the smaller and darker look of what they’re accustom to “better”, is strong.  When I change my questioning to involve becoming aware of the breath, the tension that may be present in the shoulders and throughout the body and the tone of the facial muscles, we move beyond the classic scenario of “give me the glasses so I can see” and into the space that allows us to choose a lens that provides improved ability to see things that are at a distance while working toward a more balanced system overall.
    On some level I think we all know that refractive error, most of the time, begins as the visual system adapts to some kind of stress.  Diving deep into the actual stress is often very personal and complex; and honestly, not a place most are willing to go.  But let’s go there for a moment.
    The sympathetic nervous system is often characterized as the fight, flight or freeze neurological system that allows us to respond to stress in our external and internal environment.   If we are to be engaged in the fight response, what might happen to our visual system?  We don’t need to see the details, we just need to locate and hit the target.  We don’t need to be precise.  There isn’t typically a whole lot of conscious thought involved in the fight.  Our minds and bodies are instinctually responding to the threat.  Would you say one is nearsighted or farsighted in the moment of fight? I think I could argue either depending on the scenario. I take that to mean there is a dynamic nature to how the visual system functions when under stress.  It may be difficult to pinpoint the status of accommodation, vergence and oculomotor skills.  Many of the children I evaluate present with this profile.
    What if one “chooses” the flight response? Details don’t matter.  Scan the horizon for the danger and get out! I think of this scenario as more of a farsighted posture.   You don’t need to see details close to you in order to get away from what ever is perceived as a threat.  The eyes diverge and the ciliary muscles relax to allow for a broader field of view allowing one to flee. Many children who present with symptoms of difficulty sitting still in class to “pay attention” are farsighted.  Could their nervous system be stressed and their body in a flight mode?
    Now to the freeze.  If fight or flight are not an option the nervous system resorts to this.  If the stress remains present for long enough and a person gives up the fight and feels they cannot flee, they freeze.  When one is in this state, the world around them disappears.  It’s all just too much.  Becoming closed and focused on personal preservation and survival seems like the only option.  Keep things close and small.  The accommodative system tenses and the resting position of the eyes assumes an over focused, over converged posture.  The world beyond you is scary and unsafe.  I think this sounds pretty myopic, don’t you?
    Is myopia a freeze response?
    This conversation is essential as we discuss “myopia management.”  The most common marketing message I see is that we must prevent myopia because as the eye grows the person is at risk for developing glaucoma and retinal detachments.  This is true; but there is more.  Prescribing specialty glasses, contact lenses, or using pharmaceuticals to change the posture of the muscles within the eye, for a person who is developing myopia, without considering the root causes of the maladaptive response, is not complete care.  When seeing a diabetic patient who is developing retinopathy we know we must emphasize the importance of the lifestyle changes that could change the trajectory of their condition and potentially preserve their eye sight.  We do the same for macular degeneration patients and patients with high blood pressure.  Dismissing the need to discuss myopia as an adaptation to stress, misses a huge opportunity to educate families and patients about the power they have to maintain healthy eyes.  Thinking deeply about why a person’s visual system may be developing myopia can also help ensure we work with the person and not just the eye balls.

I was in my late 20s when I first realized that clouds had volume.  That they took up space.  That there was space between them.  Sure, I “knew” that clouds had volume.  I had learned about it from Mark Brean and Steve Moleski, the local weather guys who worked at the Fairbanks Museum Meteorology department and were the radio voice for the forecast everyday.  They would come to our schools too and teach us all kinds of things that generated wonder.  But I never really became aware of the details as a kid.  I’m not exactly sure when I would have “lost” the awareness of the space around things or did I never develop it?
    When I was six years old, in the first grade, Mrs. Laird’s class, my sisters and I had a rope swing in the back yard, hanging from a huge old maple tree with the perfect limb positioned to tie a thick blue rope around.  One day my younger sister and I were racing out the back door to get to the swing.  She beat me to the door and let the old screen door snap back behind her.  It was an old kind of door that was heavy and metal, and it still had the storm glass window in it because it was early spring in northern Vermont.  The sun came out that day so we were very excited to get outside!  As that door snapped back my skinny little arm, my left arm, reached to keep the door from closing.  My hand hit the glass window right in the center and it shattered. The sharp edges of the broken glass cutting into my wrist in several places.  I don’t remember crying, although I’m sure I did.  All I remember is I got to ride in the front seat of my mother’s Chrysler station wagon all the way hospital with a blue towel wrapped around my arm to help stop the bleeding.
    Was it then that I stopped being able to observe the details of my surroundings? Was this event enough to disrupt the balance of my nervous system? Did that event impact my vision?
    A couple of months after the glass incident, it was summer.  I had turned 7 years old.  This was the summer I was going to learn to read and swim! My family was staying at a “camp”; that’s what we Vermonters call houses on the lake.  This camp was a huge old white house, up the hill from the edge of Lake Willoughby.  Lake Willoughby is a glacier formed lake with steep banks and mountains on either side.  The water’s edge was down a path through the woods and was not visible from the house.  So we kids couldn’t play in the water without the adults coming along.  My dad did the logical thing. He hung a big blue rope, with different sized loops to help position your hands and feet safely, to yet another perfectly positioned limb of a huge old maple tree to keep the kids busy.  This tree was at the top of the hill and the swing swung out over the yard that slopped down toward the lake.  The swing was really intended for my older sister who is 7 years older than me.  But how do you really keep kids from these things?
    We have pictures of me in my little pink dress, I always wore dresses, swinging happily out over that yard.  I remember the roots of the tree and how you had to have your feet perfectly positioned and the rope ready to catch your foot as you swung out.  One day, after many successful trips out over the yard, taking turns with my younger sister, cousins and friends, I missed the big bottom loop with my foot.  My hands slipped and I flew down the hill landing with my arms out stretched to break my fall.  I broke both of my arms.  Again, I don’t remember crying, but I’m sure I did.  I only remember riding in the front seat to the hospital which was about 40 minutes away.  Actually, I didn’t go to the hospital right away.  I rested with ice on my arms in the built in day bed, made of a richly colored wood, in the huge living room.  This room had huge windows facing the lake and floor to ceiling shelves everywhere made of the same richly colored wood as the day bed that was my nest for a bit.  I rested for a day or so before everyone was certain I needed to see a doctor.  Was it then that my vision shifted? Did I have whiplash? A concussion?  I was little and resilient so I don’t think it was ever discussed or entertained as anything that should be addressed.    
    Before school started the cast came off of my right wrist. My left wrist had broken in two places so that cast stayed on an extra week or so.  I still remember the doctor’s face as he cut the cast off my left wrist, with the saw he had just shown me would’t cut my skin, revealing the scars from the window incident a few months before.  I guess he didn’t have it documented that those scars had been there.  I remember my mother comforting him that those scars had been there before the casts and everyone chuckling about my being so accident prone.
    I was in the second grade.  Early in the school year it was noticed that I wasn’t reading well.  I was very inconsistent.  I would make up words, lose my place a lot and basically avoided reading.  I would schmooze on the playground to get enough information about the books we were reading as a class to pass the quizzes.  I was the only one in the class to be pulled out for reading help.  I would sit at a little white desk in the hallway, with a big window to look out of right in front of me. Mrs. Kusitch was very nice and gave me the coolest stickers, but I don’t think it helped me much, I still pretty much refused to read more than absolutely necessary.
    Someone suggested I have an eye exam, which made sense.  Both of my parents had glasses so it was highly likely in my future.  I was given glasses; +0.50 spheres OU.  If you’re in the eye doctor biz you know why I give that detail.  My mother remembers me being in awe that I could see the leaves on the trees with these new glasses.  Long story short, I continued to struggle with reading but managed to figure out a way to do well enough in school that everyone left me alone.  I joke that my Grammy Norma gave me her stubbornness and confidence to not let my difficulties doing school work bother me too much.  By the time I was in 8th grade I was wearing a highly myopic prescription, close to a -6.00 sphere in each eye.  So what do you think? Did the events surrounding my 7th birthday change the trajectory of my vision development or was it all just genetics?
    Back to that day in my late 20s.  I was already a residency trained vision therapy and rehabilitation Optometrist.  I had been through vision therapy, but in a sort of disjointed way because of the schedule I kept while a student and resident.  A lot of my vision therapy took place as I learned to teach procedures to patients.  I had been purposefully doing some therapy activities along side many of my patients for years.  I knew it look me longer than many of my young patients to see things popping out on the binocular activities but I knew I was learning along the way.    
    When I noticed the clouds, I was driving.  Headed south on Hwy 35 with the Belmar Bay to my right and rows of tightly packed houses to my left.  Stopped at a traffic light, I looked up toward the clouds to find some space.  Living on the Jersey Shore was an adjustment for me.  I was used to the mountains and open fields of Vermont and now I was living in a popular vacation destination full of people, cars and “beach houses”, many of which were no where near the beach by my definition.  All of a sudden the clouds looked HUGE and puffy.  They were moving and changing shape.  I could almost feel their softness.  I was amazed.  I honestly had never been aware of so much dimension within the clouds.  The next day I was as a park with my children and I glanced at the treelike.  And it wasn’t just a treeline.  I could see the space between the different trees and bushes.  I was in awe again.
    Sure, I could see, but was I really SEEING?  And I could look, but had I really been LOOKING?

Written in September 2022 - Marco Island Florida 
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    I love to be by myself.  I find my mind to be clearer and I have an easier time quieting distracting, unproductive thoughts. Over the past several years I haven’t had much time to myself, and the time that I have gotten, I’ve used to catch up on work or messages.  Is that really “time to myself”?  On some days I’ll take a walk to the beach and snap a picture to share with friends and family.  While I am physically by myself for this walk, am I in solitude with my phone in hand thinking I need to capture and share the moment with others?  Have I utilized my time physically alone to experience that solitude that I long for?  It seems to be very challenging to resist pulling out the iPhone, swiping up to unlock with face recognition and clicking a few times to check email, Facebook and Instagram.  It’s like a reflex.  Something that happens before I even realize what’s happening.  I’ve allowed my time physically by myself to be hijacked and am no longer alone in my thoughts. My chances of experiencing the solitude, that allows my mind to quiet and my heart to be easy, are gone.
    I’ve been trying to become more aware of these opportunities and break the habit of interfering.  One of the biggest triggers for me is my phone.  I have to leave it behind.  But as I do, I am often struck with some anxiety about many “what ifs”.  What if I have an emergency? What if one of my kids needs me? What if I need to call the police? These thoughts make my heart race and my breath shallow as I prepare for dangerous emergent scenarios that are highly likely to NOT occur.
    So the first step is calming that right away.  I often use a version of the Loving Kindness meditation to help balance my mind and body.  I am safe.  I am happy. I am healthy. I am living a life of ease.  A few recitations and I am free to leave my phone behind, entering the space of being physically alone with the chances of experiencing solitude high.
    When I allow myself to truly be alone in solitude I feel lighter and free to truly love and connect with where I am in the moment. I see things about my surroundings that I would have otherwise let go unnoticed.
    This morning I left for a walk along the shore of the Gulf of Mexico. I left my phone behind.  What if I want to take a picture? What if there is an emergency? What if someone needs me?…. I am safe… and I left the hotel room.  It was 7am. The sun had just risen but was still behind the high rises.  It took a few hundred steps to reach the water line.  I turned right and headed north along the beach with the Gulf waters and the gentle waves breaking to my left.  The crackle of shells under my feet was the only sound other than the whisper of waves as they rose and fell on the sand.  I walked about two miles up the shore to the spot where a lady had told me I would be most likely to find a sand dollar.  I had been searching for days.  As I walked, I picked up a few amazing shells, admiring the crowns of the mini conch shells and the symmetry of the color, texture and patterns on each shell that caught my eye.  But still no sand dollar.  As I neared my destination I happened upon another woman in search of a sand dollar.  We had a brief friendly exchange and I continued on.  I reached my turning point, marked by trees and brush blocking easy access to the shoreline, two miles from where I had begun.  I turned around with still no sighting of a sand dollar.  As I passed my fellow shell searcher I told her I hadn’t found a sand dollar.  She replied with, “Well, I guess I don’t need to walk that far up if there aren’t any [sand dollars] anyway.”  I responded, “each wave brings new treasures. So you never know what you’ll find.” I was trying to encourage her to continue in her search even though mine had not been successful yet.  I turned from her and walked about 10 steps, paused for a moment and decided to take off my sandals and walk in the break of the waves.  I removed my shoes placed the straps over the fingers of my right hand and watched as a hand dollar, fully intact, washed over my feet.  I immediately released my shoes to retrieve the sand dollar as my sandals took a ride in the waves.  I couldn’t risk using my left hand as that would have meant losing the collection of other beautiful beach treasures I had gathered.  As the sand dollar found its way into my hand still rolling in the waves, my heart was flooded with a sense of ease and synchronicity and then gratitude to the ocean for presenting me with this gift.  I shared my find with the lady and then headed back south, synchronizing my steps with the rhythm of the waves.