Chapter 1: The Problem of Myopia

INTRODUCTION TO THE PROBLEM

The use of refractive lenses to neutralize or palliate the symptoms of nearsightedness does not correct or cure the problem. To neutralize a problem is not to correct it, just as to treat a symptom is not the same as to eliminate its cause.

The training of professionals discourages interest in preventive and remedial treatment of refractive problems. Although most professionals would like to be able to eliminate refractive problems, this is not thought to be practical or even possible. The general attitude is summarized in the following statement:

It should be noted that the thinking of optometrists and patients alike is to prefer correction to neutralization. This is understandable; correction or prevention are the highest aims and in keeping with good health procedures. However, it is dangerous to become so determined to correct, even the uncorrectable, or to prevent, even the unpreventable, that we overlook the value of neutralizing an error for which nothing else can be done… If nothing other than neutralization can be done, it is better to know this and to educate and reconcile children to the situation than to join them and their parents in a chase of will-of-the-wisps. (Hirsch, 1963)

Attempts to prevent or remediate nearsightedness have generally tended to be oriented around the use of lenses which are designed to “relax” the strain of near work. The results of this style of prevention are ambiguous, and the majority of professionals are not convinced of its effectiveness (Borish, 1954). Other forms of therapy have been attempted.

Woods (1946) and Hildreth (1947) used optometric group training techniques; Berens, et al. (1957) used tacnistoscopic training; Kelley (195&) and Pox (1959) attempted hypnotic suggestion; Kelley (1958) did extensive individual Bates training; Giddings and Lanyon (1971 and 1974) used behavior modification, conditioning, and reinforcement techniques, as did Zeiger (1976). While the results of these experiments have shown some success in improving acuity and, in a few cases, in reducing refractive error, these attempts are considered to be impractical and have not altered the consensus “that little genuine improvement in sight witnout glasses can occur with most people having defective vision…” (Kelley, 1971). Little is done in professional vision care besides neutralizing the optical error with lenses to compensate for the problem.

There is even an attitude that nearsightedness is a positive adaptation in our society since nearsighted individuals tend to be better readers with higher levels of academic achievement. Further, it is not “now known whether disadvantages of becoming myopic outweigh advantages” (Baldwin, 1964).

One obvious disadvantage of nearsightedness is the inconvenience of wearing artificial devices on the face. The dependency on mechanical devices which can be broken or misplaced prevents nearsighted individuals from pursuing certain vocations. Another disadvantage concerns the poor self-image and feelings of weakness or inferiority which are reported by the experimenter’s nearsighted patients. Children with glasses are often ridiculed by their peers and pitied by adults. One attitude about glasses is exemplified in the following quote:

Most human beings are, unfortunately, ugly enough without putting glasses upon tnem, and to disfigure any of the really beautiful faces that we nave with such contrivances is surely as bad as putting an import tax upon art. (Bates, 1920)

The more subtle disadvantages of wearing lenses are generally disguised by our general life style. We nave come to accept as normal some rather unhealthy conditions. The eonsequence& of these “normal” conditions of modern civilization are just now being recognized by the general public. Such symptoms as cancer, circulatory and heart disorders, psychoneurotic chronic behavior, etc., are being linked to our life style (Felletier, 1977). Nearsightednesa, too, seema to be on the increase and it has been correlated with the progress of modern civilization (Batea, 1920; Young t 1965; Sato, 1964). What the consequences of nearsightednesa and of wearing neutralizing lenses might be are still unknown. Is the loss of clear vision in supposedly healthy .individuals a sign that some system in the organism is not functioning properly? Neutralization does not solve the basic problem; in fact, easy relief of the symptoms causes ua to ignore the signal of distress wnich the body is sending. Indeed, paying attention to the ways human bodies respond to the environment can lead to information about improving conditions which affect our health and can provide clues to enhancing our potential as self-actualized human be ings (Pelletier,, 1977; Segall, Campbell, and Herskovits, 1966).

The less obvious disadvantages of nearsightedness are rarely dealt witn in the literature. Methods of preventing and remediating nearsightedness are generally considered from a limited viewpoint* The neuropsychological factors concerning the etiology and mental functioning involved in the nearsighted response have not been examined in recent times. There is alao a lack of attention directed to research about the variability of and changes in refractive error in the nearsighted population.


STATEMENT OF THE PROBLEM

William Bates (1920) wrote about the importance of changing the vision care paradigm* This dissertation explores his concepts about the etiology and implications of myopia. His thinking and experience have provided a model which forms the basis for this research.

Bates was an ophthalmologist who lived from 1860 to 1931. Before his involvement in the remediation and elimination of refractive errors and other anomalies of the visual system, he had been a respected scientist, physician, and surgeon. From 1886 to 1691 he was an instructor in ophthalmology at the New York Post-Graduate Hedical School and Hospital. Later, in his ophthalmological practice in New York City, he became dissatisfied with fitting glasses. He found that once a person was fitted with glasses, the power of the lenses had to be changed and increased, getting stronger with each return visit. He began to experiment with alternative approaches to refractive problems and over a period of time developed what is now known as the Bates System of Vision Improvement.

Evidence in scientific literature that the Bates System works to eliminate myopia is practically non-existent. There are only a few cases of refractive error which any scientific study shows to have been improved (Kelley, 1958), and none for which refractive problems have been totally eliminated. Considering what is reported in the literature would likely lead to a rejection of Bates’ method of visual oare as “ta nice idea which didn’t work.”

The prevailing sentiment for Bates can be best summarized by the following quote from the major text on the history of optometry;

This was an era from which arose an unscientific and fallacious method of so-called eye exercises which unfortunately had popular appeal, The only reason this is included here is to disclaim it. In 1920, W.H. Bates, a physician of Hew York, published “The Cure of Imperfect Sight by Treatment Without Glasses.” Health cultists grabbed the idea. Untrained people began giving eye training all over the country. These people were not optometrists. The methods they used were always disavowed by the profession. The Bates and such systems of exercises by untrained nonprofessional people undoubtedly served to discredit sound visual training…and unfortunately led many people to discard necessary glasses. (Gregg, 1965)

Bates’ notions are greatly different from accepted theories of physiological optics (the science of vision):

Bates’ views are so entirely at variance with the accepted dicta of physiological optics, that the reviewer wishes to state his conviction (which he believes must be shared by ophthalmologists generally) that most of the statements quoted above are untenable, (Loeb, 1919)

In spite of an apparent lack of evidence which supports Bates, his concepts about vision problems have been reexamined. The author first encountered Bates in Aldous Huxley’s (1942) book The Art of Seeing. After personal investigation led to the elimination of the experimenter’s myopia, he became convinced of the positive aspects of his system. Since that time the experimenter has worked with patients and has achieved moderate success with the method. Bates’ concepts have been chosen to research about vision problems. On the basis of personal experiences and intuitive sense of the essential correctness of his ideas the author has researched Bates’ concepts and has found that his work is important and vision professionals should be aware of its possible utility in correcting and preventing myopia. Tne problem is an investigation or Bates’ concepts in terms of recent evidence from the biological sciences. If his ideas can be substantiated by a search of the literature and if a psychophysiological model can be developed to explain the details of his statements, then his credibility would be enhanced and research could be undertaken which might change the present vision care paradigm.

There have been difficulties in setting up programs to investigate the clinical changes in the experimenter’s Bates patients. There is a need to develop a practical method of investigating refractive changes in order to better assess the clinical success of his methods. The second part of this dissertation deals with this aspect of the problem.


RESEARCH QUESTIONS

This dissertation involves two major parts; a review and development of an etiological model from the literature followed by a study of1 refractive changes in a sample of selected myopes. Hie first part examines the following questions:

  1. Does recent psychophysiological evidence support Bates?
  2. Can an etiological model be developed which is compatible with the literature on nearsightedness based on Sates’ ideas and on psychobiological concepts?
  3. Should further research be conducted to explore Bates’ ideas?

The second part, a pilot investigation, asks a different type of question. The questions are as follows:

  1. What are the most important variables to consider in analyzing changes in refractive error?
  2. What are the moat sensitive methods of measuring refractive change?
  3. Will the results of the second study refute or support Bates’ ideas as expressed in the first study?
  4. Can baseline data be established that will be useful in future studies concerning variables which influence changes in refractive error?

DEFINITION OF TERMS

Accommodation is the ability of the eye to change its focus to allow objeeta at varying distances from the eye to be in focus on the retina.

Acuity is the ability to discriminate details, can refer to the keenness of any sensory mode.

Ametropia is a condition in which the resting eye is not able to clearly focus light from distant objects.

Astigmatism is an optical condition of the eye wherein the lens system of the eye is not curved spherically but is toroidal (shaped with the curvature like that of a football or teaspoon).

Diopter (D) is the unit of lens power measure which refers to the distance from the lens to its focal point; the stronger the lens the shorter the distance and the stronger the dioptric power used to designate the degree of ametropia.

Emmetropia is the condition wherein the resting eye focuses light from a distant object clearly on the retina without the aid of spectacle lenses.

Farsighted is the ametropic condition in which the resting eye focuses light from a distant object behind the retina. Hyperopia Is a synonym for farsightedness.

Myopia is the ametropic condition wherein the resting eye focuses light from a distant object in front of the retina.

Myope is a nearsighted person or a person with nearsighted eyes. Nearsighted is a aynonym for myopic.

Refractive error is the measure of ametropia (in diopters).

Refraction is a procedure for measuring the refractive error and determining the lena power to neutralise the ametropia.

Rx is the prescription for glasses found through refraction and written in terms of dioptric measure.

Saccadic eye movement is the movement of the eyes from one target directly to another with a quick ballistic-like movement.

Snellen acuity is a system for designating the discriminating ability of the eye for letters, usually written in the form of 20/20, 20/200, etc.

20/20 is the ability to see at twenty feet distance the same size letter that someone with normal vision can see at twenty feet.

20/100 is the ability to see at twenty feet distance the same size letter that someone with normal vision can see at one hundred feet distance.


RATIONALE OF THE STUDY

The literature on the reduction of refractive error is inconclusive. It is well established that myopia begins to show an increase around the age of five or six; it begins to increase rapidly reaching a maximum rate of increase at about the age of thirteen when it begins to reduce its rate of change. The velocity of change reduces until the late teens when it appears to stabilize close to aero (Slataper, 1950). The data of Hirsch (1952) and Sorsby (1933) are similar to Slataper’s data, Hirsch (1963) states that there is no change in refractive error between the ages of twenty and forty. However, Jackson (1932), Taaaman (1932) and Walton (1950) found that there was a significant reduction in the percentage of myopes (in the total clinical population of each study) after the late teens. The decrease in percentage of myopes (by twenty-four percent) after the age of twenty indicates a decrease in refractive error to the extent that those myopes with low enough refractive error cease to be myopes. The findings are inconsistent with the conclusion that there is no reduction in myopia between ages twenty and forty. Grosvenor (1977) indicates that there ia a lack of information about refractive changes in young adults and calls for more research,

If the research reported in the second study of this dissertation indicates that myopia can change toward improvement, this will add support for the need to engage in more intensive research to develop techniques to prevent and remediate refractive error.


LIMITATIONS OF THE STUDY

The study does not attempt to prove that myopia can be cured by Sates’ or any other therapy method. It does attempt to show that myopia is a flexible condition and is related to psychophysiological factors.

Although the refractive problems of hyperopia, astigmatism, and presbyopia are common in our society, only myopia will be considered in this dissertation. This is because the majority of patients referred to the author were myopic.

In the development of the psyehophysiologioal model of myopia the study is limited by the state of knowledge of brain function, This study represents the first attempt to establish a specific physiological process to describe the etiology of myopia. Physiological and psychological tests were not conducted on the patients in order to confirm the model. The correctness of this approach is inferred from past studies on the characteristics of myopic patients.

The study of refractive changes in the patients is not an experiment but a retroactive examination of optometric data collected In the office. This is a pilot study on existing data which is designed to aid in the development of future research, limited to little specific data about personality or life style characteristics of the patients. It is limited also by the small sample size (fifty five patients).


SUMMARY AND OVERVIEW OF REMAINING CHAPTERS

This chapter has described the attitudes of the visual health care profession concerning the prevention and remediation of nearsightedness. On the one hand it is emphasized that it is important to increase the state of our knowledge regarding the refractive anomalies of the eye, and on the other are advised that it is impractical and even a disservice to patients to attempt to prevent or remediate nearsightedness.

The literature has not dealt with the humanistic implication a of conditions which produce myopia in the affected one eighth of the population. It has also ignored the ideas of William Bates, a major researcher who established a holistic model of vision and a method of remediating refractive problems. This dissertation is an attempt to establish the credibility of Bates and to reexamine his ideas with reference to modern neurological concepts. There is no intent here to prove conclusively that Bates’ method represents a cure for myopia. The present study is designed to explore the methods necessary to prepare a reliable data base for future experiments which might study the complex problems of refractive change in young adult myopes. In addition, the study may be able to determine the difficulties an experimenter can expect to encounter in designing such a study.

Chapter Two reviews the literature concerning refractive changes in the population and on approaches regarding the etiology of myopia. It includes an in depth investigation of Bates’ concepts of the etiology of myopia. This section relied heavily on the work of Karl Pribram, whose research was reviewed with special emphasis on factors which relate to vision and attention. This research provides a neurophysiological framework for the examination of Bates’ ideas about vision. It also provides a model of causation which is compared to earlier research on etiology of myopia.

Chapter Three presents the methods and procedures of the pilot study.

Chapter Four presents the results of the data analysis. Chapter Five discusses the results, reviews the research questions, draws implications and provides suggestions for future research.

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