You may not be familiar with The American Scholar and, if not, all you need to know is that it is the quarterly journal published by the Phi Beta Kappa Society. The Spring 2023 issue contains a thought-provokiing piece by Caitriona Lally titled Phantoms: What it’s like to navigate the world when your senses conure up phenomena that others can’t perceive.
The lead item in the article was tinnitus, and because it address the senses broadly I expected the author to use Visual Snow Syndrome as the new prototypical example of the subtitle. But she surprised me when she wrote:
“In childhood, my eyesight was below par, but as with my hearing, I learned to compensate. When I was 12, a nurse visited the school to test the students’ eyesight. We were brought in groups to the staff room, where an eye chart had been placed at the end of a long table. I angled myself into last place so that I could listen to the full-sighted children before me reel off the letters. In this way, I was able to memorize the last few lines of the chart. I got away with it—but what did I get away with? I managed to avoid a prescription for the glasses I objected to. But this meant that the rest of my schooldays were spent peering at a blur of chalk shapes on the blackboard. I learned to guess at the meaning of a sentence from the few words I could squintily decipher, in the same way that I guessed at what words had been spoken from the few words I could catch.”
Caitriona is describing the way some children game the system of vision screening in school. But even when an eyesight flags down a child and her parents dutifully take her for an eye exam, she may resist wearing the glasses prescribed. Not necessarily because she doesn’t like her appearance in spectacles, but because the doctor insists on Rx-ing the full power to 20/20 or beyond. Many eye clinics post a “Patients Bill of Rights”, principally for medico-legal reasons. You’ll rarely if ever see one of those bullet points as the right not to be prescribed glasses providing the sharpest distance eyesight possible.
As Caitriona describes it, her visual world changed dramatically and suddenly after refractive surgery:
“I got so used to living in a blur that when I got laser eye surgery in my 30s, I was perplexed by the amount of detail that had presumably always been in my surroundings. The day after the procedure, I looked out the car window and saw, for the first time from such a distance, individual leaves on trees. I had only ever seen blurry lollipop tree shapes from a child’s drawings, and suddenly here was high-definition detail that had been right there all along. That night, I looked out the window and saw stars actually twinkling: so this was what the nursery rhyme had been on about!”
When we prescribe low power plus lenses and/or prism to aid reading, we occasionally have to advise parents why a child doesn’t understand the need to wear glasses. “But I see fine”, they say. Or, “I don’t see any difference when I put the glasses on” they may claim. We have to find the right words to explain that the Rx doesn’t change eyesight, but changes the way the child is able to focus or concentrate or process the information visually. “That’s quite different from someone who puts on glasses and says ‘wow, I can see the trees on leaves from across the street!'”. It probably follows the Pareto Principle that 80% of patients will be delighted with an Rx that makes distance as sharp as possible, though the actual percentage may even be higher. But Caitriona isn’t among the eighty percent.
In fact, for those of us who have specialized practices, the percentage of patients who are visually sensitive is considerably higher. They experience a type of sensory overload, or hyper-stimulation when thrust into a world of high resolution, central vision, or hyper-focalization that doesn’t benefit them. As Caitriona explains:
“Watching a film in the cinema was now an exercise in overstimulation. I found it hard to unfocus from the details and couldn’t keep up with chase scenes in action movies because I would home in on the wrong things. I used to be swept along by a vague rush of movement, but now I wanted to pause and examine the details. Perfect vision brought self-consciousness, however. Seeing imperfectly means you assume that others see what you see, which allows you to exist in a mythical, nonjudgmental world, unseen. Walking up a busy shopping street for the first time postsurgery, I was intimidated by how close the other people were and how much eye contact they made. I preferred to think that people saw as little of me as I did of them. The ground felt too close. It seemed to rise up to my knees, and I found myself taking exaggerated steps, as if I were walking up a flight of stairs. Being naked in the public baths and hot springs of Japan had been fine presurgery. Feeling so unseen was both comfortable and liberating, and because this was a time before phones had cameras, I wasn’t screen-seen either.”
Don’t dwell on the fact that she is equating vision with eyesight. If nothing else, it underscores the fact that we continue to fight an uphill battle on helping the public understand that distinction. Dwell instead on how well she describes the changes to her visual perception as impediments to which she had to adapt. Changes, I would suspect, that no one counseled her about. She continues:
“Similar to tinnitus, laser eye surgery added impediments to my vision by introducing things that existed only in my head. A too-bright halo now appeared around lights; looking in the general vicinity of a light meant I couldn’t see around it. If I tried to flag down a bus in the darkness, I struggled to see the number of the bus if it was near the newly haloed streetlights. Also, the surgery seemed to introduce dark maggot-size shapes in the periphery of my vision. Switching from near sight to far sight brought on a bout of the maggots, which were hard to ignore at first, but I learned to forget about them. If I’d had this surgery as a child, I probably would have explained the maggot shapes by assuming the scalpel had implanted them in my eyes.”
The last line of her essay is telling, as Caitriona concludes: “I can only know myself as I am now, slightly off-kilter with the rest of the world”.
If you don’t have a primary care practice, or if primary care comprises a comparatively small component of your practice, no doubt you will care for many patients who feel slightly-off-kilter with the rest of the world. They will seek you out because of the reputation that you have for negotiating a compromise between the way the world appears to be and an idealized view of the Snellen Chart to which most eye doctors still adhere.
In our practice, we no longer accept patients for “routine eye care”. Once we have arrived at a comfortable compromise between the way the world looks and the way it feels, we strive to maintain that balance on successive visits, Paradoxically, the challenge becomes that that these patients are reluctant to leave your practice. In a sense, you have become a victim of your own success. While that may be flattering at first, and in one way can be good for business, it may constrain your ability to see new patients. And where else are these patients to go?
One thing that we commonly look at is what is the eyesight with a static position. I’m beginning to believe that it is the visual motion processing system(dynamic vision) that is affected by the lens. A minus lens tends to decrease the VOR gain and a plus lens increases the VOR gain, and then the patient must use neural integration(INC and NPH) as well as the cerebellum to modulate the system back into balance so that the head movement and ocular movement coincide. It is not uncommon that when you approach these kinds of patients and help them relearn to see more peripherally, that their world becomes more stable.
Point well taken, though in many cases of “visual sensory overload” with full minus it is a minus lens in both cases – and just a matter of how much minus, not minus versus plus.
Fascinating post, Dr. Press. The poor lady now has to reintegrate a whole new world of sensory data with movement. What we perceive are opportunities for action. She has to relearn to see, to understand what opportunities for action the sharply focused details afford. Novel worlds also invite us to leave our habitual seeing to explore. We continue to explore until we can put the world back on automatic. I would imagine she is overwhelmed. Thanks for this thought-provoking piece.
You’re welcome, Dr. Cook.