Optometric opinion on "prevention" -- and difficulties.

Discussion in 'Optometry Archives' started by Otis Brown, Sep 1, 2003.

  1. Otis Brown

    Otis Brown Guest

    Dear Vision Research Group,

    Subject: Comments concerning "Prevention" in optometry.

    Re: Preventing Refractive Error: What's a Doctor to do?)
    Merrill D. Bowan, O.D.

    The following is some commentary on "What is a doctor to do",
    about nearsightedness.

    What follows contains some extracted items. I also supply some
    short commentary.

    These are "behavioral optometrists". I appreciate there
    "forward looking" approach, but they do not mention the need to
    change "public attitude" towards the plus. Until that attitude
    can be changed, I am afraid that prevention will be difficult or
    impossible for most people.

    I wish I could be more positive -- but the failure is in the
    "public mind" and not in the optometrist.

    My approach is AN ATTEMPT to change the "public mind" about
    the issue -- however difficult it may be to do that.

    The "academic stone-walling" by Scott is honest -- but very
    destructive. [i.e., the Donders-Helmholtz pure box-camera theory
    of the eye, which represents the eye as being "defective" because
    it has positive and negative focal-states.]

    But that is a major issue indeed. Prevention is indeed
    difficult. But the "ethical" issues of using a plus on a child
    with 20/30 (focal state zero) has never been faced, let alone







    (Original title:

    Preventing Refractive Error: What's a Doctor to DO?)

    [Available from The Optometric Extension Program as Tape
    #WK-4 from the 3rd International Congress of Behavioral Optometry]

    Merrill D., Bowan, O.D.


    My premise is that refractive error is disease. Myopia is a
    lesion. Astigmia is a lesion. Hyperopia (in the range of adverse
    hyperopia, which clinically appears to be that greater than 1.00),
    is a lesion.

    Myopia, astigmia and hyperopia have already been described as
    adaptive stress diseases. You have a list of my papers in the
    program that will give you a more in-depth understanding of how I
    have come to the conclusions you are about to hear. I invite you
    to listen carefully to see if you find exception with what I am
    about to say.

    [ O/H #1 - Paradigm Shift]

    [CHICK, standing beside open eggshell:
    "Oh WOW! Paradigm shift!"]

    Optometry has been in a shell for too long: the shell of the
    medical model, or the classic eye-ball model, or the merchandising
    model. It is time for optometry to come out of its shell and open
    its professional eyes to a whole new paradigm: Refractive Error
    As Adaptive Disease.

    Skeffington was only one of the first of our professional
    fathers to point out that;

    [O/H #2 - Refractive Error]

    [Refractive error is the last stage of a visual problem.]

    People may think that it is a bad thing to be myopic, or
    hyperopic, or astigmatic, but to the body, these are good things,
    not bad. They reflect and reinforce the way the body has chosen
    to cope. Myopia is a wonderful way of pulling a spatial problem
    in to assimilate it. Hyperopia is a wonderful way of pushing it
    away, glossing it over, or running away from the problem.
    Astigmatism is tricky - it is part of the transition to myopia, or
    the body's concession when it wants to run away, but is being
    constrained to perform.




    Bowan> Q. But what are the best things that can be done for

    Bowan> A. Work to prevent progression of nearsightedness, once
    it's started. The only real cure for myopia is to prevent
    it. You have to understand what myopia is.


    Bowan> 3) Preventive lenses - "Plus 0.50" or "Plus 0.75" reading
    lenses are powerful tools against myopia for most
    students, beginning as early as second grade for most,
    though some students are showing signs of this
    developmental nearsightedness by the middle of first
    grade. Personality style analysis can help to detect
    earlier need for these "brain glasses", as they're
    sometimes called: children prone to myopia seem to be the
    sort who are intelligent, analytical, withdrawn,
    stress-absorptive, under-active children, who are driven to
    please their superiors. Bifocals with clear top portions
    are sometimes a more practical way to provide the reading
    lenses without the bother of taking them off to see
    distance objects.


    Bowan> Stop and think: we can't - shouldn't - go fitting glasses
    and contacts onto living, thinking persons like their
    eyeballs were mounted on an optical bench, yet that is
    what is done in 90% of the offices in the world.

    Bowan> ...Our alternative is to do nothing and watch them get
    worse. This should be found unethical and morally
    intolerable by the caring clinician. We do know what to
    do - it's almost too late, but we need to begin to do it.

    Bowan> Unfortunately there is no coordinated effort in exploring
    the domain or scope of refractive error. Hyperopia is
    treated as a non-problem, astigmatism is a nuisance and
    myopia is regrettable.

    Bowan> Any discounting of refractive error is in error.
    Scientists and clinicians call for proofs yet many of them
    are just defending their own inertia. They do almost
    nothing for their patients` welfare while they take the
    money to the bank and wait for "George to do it" -
    ametropia research, that is.

    Bowan> Returning for a moment to consider the animal studies, the
    results are quite exciting (one hardly knows what to
    expect, actually). The results vary on whether you use
    white or black occludes, minus or plus lenses (which has
    been hit or miss within studies), form deprivation only,
    total deprivation or partial deprivation, what animal and
    what species of animal (Rhesus and Stump-tailed Macaques
    have different responses). It is all a bit mind-boggling
    in complexity. 25

    Bowan> Then, once again, as Zadnik questions, is it relevant to
    humans? These animals correspond to humans under six
    months of age and with some rare exceptions that will
    produce form deprivation myopia in humans, no visual
    deprivation of similar magnitude occurs in children. 25


    Bowan> These experiments are distracting to the average clinician
    who wants to help prevent visual problems and enhance a
    person's visual and cognitive performance. It is as if we
    have left sound and productive methods and research behind
    because of various investigators who are infatuated with
    novelty. We need to have reasonable approaches: we would
    like perfect, proven approaches, but we are not going to
    have these for another 10-20 years - and only if we can
    get out of the experimental rut we are in. We have lost
    valuable time, I believe, because we as
    neuro-developmental optometrists have not been assertive
    about what we know and do every day. It is time to stop
    being wimpy and get to the research labs with the old
    models that worked so well. Not perfectly, mind you, but

    Otis> While I can understand the above sincere statement,
    "experiments are distracting", ultimately scientific truth
    about the dynamic behavior of the natural eye is in the
    experimental data itself. ** There is a honest disconnect
    between what the experiment tells us about the behavior of
    the fundamental eye, and "what the public will accept" from
    an optometrist. This is very difficult, and both "we the
    public" and the optometrist must understand that "change"
    requires that "the public" change its attitude towards the
    use of the plus with the eye at 20/20, but a focal state
    of zero.

    Otis> It is considered "un-ethical" for an optometrist to place a
    Plus-one on a child with 20/20 and a focal status of from
    zero to +1/4 diopter. Unless the parent will "accept"
    this necessity, effective prevention is not possible, in
    my opinion.

    Otis> My parents were informed that I (at age 6) was going to be
    nearsighted. The ophthalmologist said nothing more than
    that. It seems wise to take the first step of INFORMING
    the parent about the use of a plus-one at that point.

    Otis> The parent may "explode" to think that his child with 20/20
    "needs glasses", but that issue needs to be "thought out"
    by the parents. If the parents think the use of the plus
    is a "joke", then no further conversation is going to take

    Otis> We need an "educated" public on this matter. Without that
    kind of "smarts", prevention will always "fail" -- not due
    to "scientific fact" but because of public "attitude" and


    "It seems that the human mind has first to construct forms
    independently before we can find them in things. Kepler's
    marvelous achievement is a particularly fine example of the truth
    that knowledge cannot spring from experience alone, but only from
    the comparison of the inventions of the mind with observed fact."

    Albert Einstein
    Otis Brown, Sep 1, 2003
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  2. Otis Brown

    Otis Brown Guest

    Dear Mike,

    Subject: Sorry for the typo, thanks for correcting it.

    A focal state of zero (or some positive value) if found by
    having you read the 3/8 inch characters at 20 feet. This
    is called 20/20. (Sorry for the 20/30 typo.)

    If a +1/4 diopter lens (from the trial case) JUST BLURRS
    the 20/20 line then you have no "hyperopic reserve".

    If you run this test, you will find a population of
    normal eyes have focal states running from zero to
    +2.0 diopters.



    Otis Brown, Sep 2, 2003
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  3. (Otis Brown) wrote in @posting.google.com:
    Again, Otis, please do your best to cite me correctly and not put words in
    my mouth. I've been criticizing your approach, your controls, your
    methodology, your subject pool, the relative importance of a positive
    finding from a public health point of view, and the ethics of using
    children in these studies. I have NEVER advanced one hypothesis over
    another. Just because I'm criticizing the approach doesn't mean I'm
    criticizing the hypothesis (regardless of how amorphous that hypothesis
    is)--it just means that I don't believe you will get a meaningful answer
    with the studies you're proposing.

    I'm being very clear and consistant. Please try to avoid putting words in
    my mouth.

    Scott Seidman, Sep 2, 2003
  4. Otis Brown

    Otis Brown Guest

    Dear Scott,

    Thanks for your corrections. So their is clarity
    with people who are interested in "prevention"
    I will post your statements to them.


    Otis> I like to see individual pilots clear their vision
    from 20/40 to 20/20. Yes, it takes a great commitment
    and effort -- but they see the results themslves.
    Perhaps that is the ONLY WAY a pilot becomes
    convinced as to the necessity of using a +2.5 diopter
    lens for all close work (and "pushing print" to boot).

    Otis> Obviously a pilot who does this has taken legal
    responsibility unto himself to do this work
    and Dr. Stirling Colgate and Captain Fred Deakins
    did. Perhaps this defines and separates the
    "enginering" approach from the medical approach.

    Scott> (regardless of how amorphous that hypothesis
    Otis> I don't think so -- but we disagree on ths point.

    Otis> Let us use clear and simple language to describe
    the dyanamic behavior of all natural eyes -- starting
    with the term "focal state".
    Otis Brown, Sep 2, 2003
  5. (Otis Brown) wrote in @posting.google.com:
    When I see a scientist start a talk by defending his coordinate system, I
    get ready for a long, boring talk from which I will learn little.

    Scott Seidman, Sep 2, 2003
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