Thoughts on Myopia... nearsightedness

 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.