Judy is confused -- about assignment of responsibility

Discussion in 'Optometry Archives' started by Otis Brown, Aug 26, 2004.

  1. Otis Brown

    Otis Brown Guest

    Subject: Who is responsible for inducing fundamental change?
    You or the OD? Who has the motivation to start
    a process of fundamental change (for prevention)?
    Who suffers the consequences of over-prescription
    of a minus lens?

    Re: Raphaelson "solved" the problem of
    nearsightdness-prevention 100 year ago.
    (Read Chapter III, "How to Avoid Nearsightedness")

    Yes he did! And what happened -- the "Printers Son" rejected
    it. So that was the end of that. So the consequence of that
    rejection (-1/2 diopter per year) must be the responsibility
    of the person who did the rejection -- in my opinion.

    So now the great majority of ODs "talk around" the subject --
    never pointing to the child's "bad habits" as being directly responsible.

    If some one gave me "straight, honest talk" about this issue
    -- then I MIGHT be able to do it myself. If I do not -- the
    responsibility rests on me -- alone.

    Here is "Dr.Judy" and her artful ways of avoiding that
    issue. As she, says, most people have no interest, and
    for them perhaps there is no answer other than the minus lens.

    For your thoughtful review. True responsibility rests
    with all of us.




    Subject: The OD Cop-out.

    Or why a large number of ODs believe that they have no
    responsibility to discuss true-prevention with you.

    Re: > So, even if near work causes myopia -- and the
    plus-lens use prevents it -- how do we avoid the risk causing
    moderate to high hyperopia in 75% and illiteracy in 100% to save
    25% of children from myopia? DrJudy.

    Dear Friends,

    "Dr" Judy has jumped to a whole series of false conclusions
    about the correct use of the plus lens at the threshold.

    I will say this -- if anyone wants to "work" this issue of
    true-prevention they should stay away from Dr. Judy -- as far
    away as possible!

    She uses a false concept "the box camera theory" to describe the eye,
    i.e., a focal state (emmetropia, 0.0 diopters) is the normal eye.
    That means, automatically that you are either "nearsighted" or
    "farsighted", i.e., myopic or hyperopic. There is no such thing
    as a "normal eye".

    Once she gets away with using these "false words" to describe
    the natural eye, she then can say almost ANYTHING she wishes to
    say -- however mis-leading and evasive.

    The entire process of "clearing" your distant vision from
    -1.5 diopters to +0.5 diopters means that the natural eye MUST
    change its refractive status by +2.0 diopters, i.e., you go from
    "myopia" to "hyperopia". Thus your eyes are NEVER normal,
    by using the "false words".

    She then talks about "causing" hyperopia, as though it is a
    TERRIBLE situation in an adolescent!

    In fact, the natural eye (in a open environment) has
    refractive states that are all positive -- 0.0 to +2.0 diopters.

    To call natural and normal refractive states "defects" or
    "errors" boggles the mind.

    I have no idea where she gets the "... and illiteracy in
    100% to save 25% of children from myopia". First of all, I do
    love to read. Secondly, I do not like becoming nearsighed -- if I
    have a choice to avoid it -- even if it DOES REQUIRE that I always
    use a strong plus for all close work. That is MY CHOICE. I only
    need to be taught HOW to use the plus correctly. The rest must be
    up to me. I would appreciate clear information about this effort
    being supplied by Dr. Judy, since I judge that she is OBLIGATED
    to supply that type of information. Any hope she ever will do

    If this "Dr Judy attitude" is true for 99 percent of the ODs
    -- that she is going to do NOTHING for prevention, for fear of
    "causing 100 percent illiteracy", in the population, then that
    "forces the issue". It this a statement of a person with any
    common sense at all?

    I now have no choice but to learn from other sources (other
    than Dr. Judy) how the eye actually behaves, and apply that
    knowledge to my own preventive efforts.

    I have developed my site to help a others learn of these
    issues. I truly hope that a more positive attitude could be
    developed in "Dr Judy", but for now I know that is impossible.




    From: Sci.Med.Vision

    Cathy> Please, provide some evidence that the environment for
    myopes differs from that of non-myopes.

    Judy > Myopes are known to have a reduced sensitivity to retinal
    blur...to myopic blur. They are quite responsive to
    hyperopic blur.

    Cathy> Are you saying this reduced sensitivity to myopic blur,
    which explains why their eyes do not notice that they have
    become myopic and therefore do not self correct, is not

    Judy > ...and an increased rate of growth of the posterior chamber
    of the eye even before they become myopic.

    Cathy> As they passed from hyperopia to emmetropia before becoming

    Judy > Yes, most myopes pass from hyperopia to emmetropia before
    becoming myopic. Most myopia does not develop until after
    the age of 10, before that they are hyperopes.

    Judy > Size of the eye, corneal curvature and refractive error in
    babyhood / early childhood (all congential features) can be
    used with some accuracy to predict who will become myopic
    later in life. Numerous studies have studied populations
    of myopes for common factors; family history remains the
    single best predictor of and risk factor for myopia.

    snip -------------

    Judy > But I can't see a practical way to change the environment:
    if we restrict near work and reading and use plus lenses
    for all children we risk causing moderate to high hyperopia
    in 75% and illiteracy in all to save 25% from myopia; not a
    good risk/ benefit ratio.

    [Otis: This again boggles the mind. The "practical" manner is that you
    use the plus to change the accommodation signal. Jeeze!
    Further, here she goes again with "causing
    hyperopia", which in broad perspective, means helping the
    eye to change to a normal and valueable positive refractive
    status! OSB]

    Dr Judy

    Cathy> Thank you for acknowledging the negative effects of
    excessive near work and the positive effects of plus

    Judy > I am not acknowleding them, only stating that IF they
    exist, then how do we provide a practical treatment.

    [Otis: Notice how DrJudy does not acknowledge ANY FACTUAL,
    SCIENTIFIC TRUTH as she manages to maintain her position as
    "expert". OSB]

    Cathy> They are too big a risk for emmetropes and hyperopes. How
    is it that you can name a bunch of myopia predictors -- but
    can't see how to treat only those who exhibit those
    predictors? As I've said before, only those children
    exhibiting myopia need countering plus lenses. Certainly
    those who have trouble seeing can be distinguished from
    those who do not.

    Judy > We can determine who is actually myopic on an individual
    level. Human clinical trials have not shown any
    significant effect in treating myopes with plus.

    [Otis: Here again Judy is selective. Only the screwed up
    bi-focal studies "count". The "quality study" by Francis
    Young is not mentioned nor respected -- even as "the second
    opinion". OSB]

    Judy > The other predictors that are present before myopia exists
    only work on a population level, i.e., a population with a
    family history of myopia, high corneal curve etc will have
    a greater risk of developing myopia. On an individual
    level, the normal range is so large that it is not really
    possible to pick out individuals who will become myopic
    with enough certainty to risk treatment.

    [Otis: "Risk Treatment?" What is the risk? That the individual
    will clear his vision by getting his refractive status to
    move from a negative value to a positive value? What
    about the risk of the minus lens -- that you will develop
    "stair case" myopia? I guess that responsibility is
    assigned to the person as his "bad heredity", never a
    "responsibility" of Dr. Judy. I bet she never mentions
    any of these minus-lens risks when she places that first minus lens on
    a child. The worst part of this is that the "Dr. Judys"
    will sit on the "Boards of Optometry", and virtually
    control all the other optometrists to follow this "party
    line". OSB]

    Judy > For example, the group with "K" readings above the population
    median will have a higher percentage of myopes than the
    group with K reading below median, but there will be a
    number of individuals who are not myopic in the above
    median group and a number of individuals who are myopic in
    the below group.

    [Otis: Wow! The "risk factor" for nearsightedness is:

    1. Your refractive status is 0.0 to -1/2 diopters.

    2. Given that the "bifocal" studies show a standard -1/2 diopter
    per year, it follows that it is virtually certain that the
    person will get very seriously nearsighted if NOTHING IS

    3. Dr Judy feels she has no responsibility to mention any of
    these issues to the person. Obviously, in HER MIND, it is not HER
    RESPONSIBILITY. Therefore it must be the responsibility of
    the poor child that is going to get a strong minus-lens.]

    Judy > So, even if near work causes myopia -- and plus-lens use
    prevents it -- how do we avoid the risk causing moderate to
    high hyperopia in 75% and illiteracy in 100% to save 25% of
    children from myopia?

    [Otis: After all of this, I strongly suggest that the plus is the
    "second opinion" that MUST BE ACCEPTED before the minus
    lens is used. If the parents and child REJECT the plus at
    the threshold -- then for that child, true prevention is a
    "lost cause". But the real issues is "who is responsible"
    -- because sure as hell, Judy is taking no responsibility!]



    Dr Judy
    Otis Brown, Aug 26, 2004
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  2. Otis Brown

    Dr Judy Guest

    I , other eye doctors, vision scientists and vision researchers do not use
    the value laden term "normal" (implying that myopia and hyperopia are
    abnormal) to describe emmetropia, . Only you use that term and only you
    consider non emmetropic eyes to be abnormal.

    Vision scientists need to precisely measure and describe refractive error.
    The precise definition of emmetropia is "image of object at optical infinity
    is focused on the retinal plane when accommodation is at rest", myopia is
    defined with the image in front of the retinal plane and hyperopia is
    defined with the image behind the retinal plane. These are the accepted
    definitions, live with it.
    If you feel a need for eyes to be called "normal", try using either
    uncorrected or corrected visual acuity instead of refractive error in your
    definition. Feel free to specify any minimal level as "normal". Some
    examples for best corrected in current use are:
    20/20 as "normal" for flying Navy planes
    20/30 as "normal" in amblyopia treatment
    20/40 to 20/60 as "normal" for driving
    better than 20/200 as "normal" for legal/ tax benefit purposes

    Generally, we don't consider an eye abnormal if vision can be corrected
    with refraction. So there are fewer samples for uncorrected definition in
    current use. Here is some:
    20/20 as "normal" to apply to some local police forces
    20/40 as "normal" to apply to the RCMP
    20/40 to 20/60 as "normal" for driving without glasses

    If you were to use best corrected VA of better than 20/40 as your
    definition, you would likely find close to 90% of people to be normal.
    Using 20/200 would define about 95% as normal. Even if you use uncorrected
    VA of better than 20/40, you would get about 70% of pre presbyopes and close
    to 50% of presbyopes as normal.
    Well it is. Hyperopes will often experience discomfort, headaches and even
    double vision at near and may have symptoms at far as well. The biggest
    risk however, is that hyperopia is associated with poor reading, learning
    disability and poor school performance.

    J Am Optom Assoc. 1986 Jan;57(1):44-55.

    Refractive error and the reading process: a literature analysis.

    Grisham JD, Simons HD.

    The literature analysis of refractive error and reading performance includes
    only those studies which adhere to the rudaments of scientific
    investigation. The relative strengths and weaknesses of each study are
    described and conclusions are drawn where possible. Hyperopia and
    anisometropia appear to be related to poor reading progress and their
    correction seems to result in improved performance. Reduced distance visual
    acuity and myopia are not generally associated with reading difficulties.
    There is little evidence relating astigmatism and reading, but studies have
    not been adequately designed to draw conclusions. Implications for school
    vision screening are discussed.

    The relationship between moderate hyperopia and academic achievement: how
    much plus is enough?

    Rosner J, Rosner J.

    University of Houston, College of Optometry, Texas, USA.

    BACKGROUND: There is evidence linking uncorrected hyperopia in children with
    academic learning problems. METHODS: This study was designed to test that
    hypothesis and--given supportive data--to then address a second topic: the
    minimal amount of uncorrected hyperopia that appears to impede elementary
    school performance. RESULTS: The refractive status and achievement test
    scores of 782 first-through-fifth grade children were compared. CONCLUSIONS:
    Statistical analysis indicated significantly lower achievement test scores
    among hyperopic children whose refractive errors exceeded 1.25 D (ANOVA F =
    12.51; df = 4; p = 0.014).
    As stated earlier, refractive error is the accepted term; "defect" is
    neither used nor implied. Only Otis calls refractive error a "defect" and I
    agree that calling it a "defect" boggles the mind.

    I was replying to suggestions by Cathy Hopson that if school children
    genetically likely to become myopic used high plus (+10 to +15) full time
    for several hours a day or greatly restricted near work that myopia might be
    prevented. Since we can't predict who will become myopic, I was pointing
    out that, if the animal models are relevant to humans (another topic
    altogether), then the not predestined to become myopic plus lens users would
    become +8 to +13 hyperopes and all kids would be illiterate due to lack of

    What do you mean by obligation? I am obliged, as a health professional, to
    obtain informed consent from patients before starting therapy. That means
    providing to them the pros and cons of the therapy including success rate
    and risks.

    For your proposed plus lens therapy I would be obliged to say:

    "There is a therapy for preventing myopia that, in human clinical studies,
    has been shown to not work and to possibly increase the rate of myopia
    progression rather than decrease it. If you are not yet myopic and do not
    have the genes that will make you myopic then the therapy will likely make
    you more hyperopic. There is no test to tell if you have the myopia gene,
    so we cannot know in advance if the therapy will prevent myopia and leave
    you emmetropic or if it will make you more hyperopic. If this therapy is
    for your child, then I must also tell you that hyperopic children have more
    problems with reading and poorer school performance than lesser hyperopic
    children and myopic children."

    How many parents will want to try this unproven therapy that may make their
    children poorer readers?

    Of the body of research on the use of plus to prevent myopia, one study
    (Young) showed a clinically significant effect and one study (O'Leary)
    showed that it made things worse. The rest showed little to no effect. So
    Otis, here is an offer. I will stop quoting O'Leary if you stop quoting
    I have mentioned the risk of causing hyperopia.
    about the risk of the minus lens -- that you will develop
    Please provide evidence that stair case myopia exists. The animal studies
    did not find it.

    snip rest of message

    Dr Judy
    Dr Judy, Aug 27, 2004
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  3. Otis Brown

    Cathy Hopson Guest

    No suggestions were made to use high plus for several hours a day on
    anybody. The studies referenced showed that a few minutes of high plus
    counters the effects on axial length of a whole day of hyperopic defocus. I
    suggested applying the idea to those who have already exhibited myopic
    symptoms. Your erroneous line of thought that this would cause illiteracy
    does not follow.

    If the method was to be misapplied, you should be able to catch the
    hyperopia before +8D, or, most likely, your patients will. Again, your
    argument presents, but you don't recognize, environment trumping genetics.

    Cathy Hopson, Aug 27, 2004
  4. Otis Brown

    Dr Judy Guest

    If a few minutes a day of myopic defocus is enough to prevent myopia, then
    how does myopia ever develop in the first place, as nobody spends all day
    with near work? When I put that question to you earlier, you stated in
    "Certainly the 30% that are myopes need closer to 50% of their time spent
    viewing real distance, not just barely over one meter, to keep from
    progressing due to near work. It's
    likely you would find emmetropes and hyperopes can handle near work at other
    points of the 50% to 90% range, but that's another discussion topic."
    I think we have a disagreement on the meaning of genetic vs environment
    cause. Further discussion is futile until we agree on terms.

    By genetic, I mean that either the person has an unusual genetic response to
    a normal environment (a response that people with different genetic makeup
    do not have) or the environment does not affect the response at all . For
    examples: eating wheat causes gastric damage in people with the celiac gene
    but does not harm anyone else. The colour of my eyes is independent of

    By environment, I mean that the person has a normal genetic response to an
    unusual environment, and that unusual environment causes the same response
    in all. For example, air pollution and smoking causes damage to lung tissue
    in all people. Severe malnutrition can cause my hair to thin, fall out and
    fade in colour. Exposure to sun causes my skin to tan.

    With myopia, I have not yet seen an argument that something in the
    environment causes myopia. The animal studies were looking at how the
    visual system recovers from refractive error present at birth, they do not
    provide insight into how myopia develops after birth, nor do they provide
    evidence that near work is the primary cause of myopia. Human studies have
    consistently found that family history of myopia is a strong predictor of
    myopia and near work is not.

    Dr Judy
    Dr Judy, Aug 28, 2004
  5. Otis Brown

    Cathy Hopson Guest

    Do you really see the same response, i.e., no range of response, in all who
    are exposed to the sun? Do you really not see the sun as a viable component
    of a normal environment?

    Do you really still see family history as only a genetics source? When
    adults smoke, saying they grew up with it, do they smoke because of family
    history genetics? The damage response of smoking is, again, a range of
    response. It is not the same for all. By your definition, doesn't the var
    iance of a little lung damage in some and cancer in others mean it has a
    genetic cause? But you named lung tissue damage from smoking as an example
    of environmentally caused, the same response for all.

    We can agree on terms when they make sense beyond your own convenience. I
    know what you're trying to say just as well as you know what I'm trying to
    say. We don't even agree on the meanings of near work, plus lens, research,
    and purpose. You also seem to be substituting near work when you mean
    accommodation. I argue only from what ODs on this newsgroup have presented
    as support for their positions, without accepting unsupported conclusions,
    of course. Want to try another set of made-up definitions, or shall we call
    it a day?

    Cathy Hopson, Aug 29, 2004
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