Eye doctors spend a good part of their lives working in dark rooms. When we pick up a retinoscope to assess the vision of a very young child, or gaze into the oculars of a microscope to find those few elusive cells that are the hallmark of inflammation in the anterior chamber, we dim our examination rooms to a perfect pitch black; a velvety, palpable darkness, in which we can bend light to our will. Darkness is an integral part of our daily existence, but how often do we ponder its meaning? Have we considered what darkness does to our patients, how it affects their behavior and interactions, what effects it has on vision?

Let’s start with the psychology of darkness. Researchers of the 1960s and 1970s found that the hours of darkness showed an increase in criminal activity and that bringing better lighting to city streets reduced crime anywhere from 33 to 70 percent. A study published in the journal, Psychological Science, by Chen-Bo Zhong and Vanessa Bohns of the University of Toronto and Francesca Gino of the University of North Carolina, found that subjects tended to lie or cheat more under the cover of darkness than in a brightly lit room. Adding eight additional fluorescent lights reduced dishonesty by about 37 percent. They found that darkness created a semblance of anonymity, which in turn, increased morally questionable behaviors.

What about fear of the dark? Why do children universally fear the dark? We can conjecture that evolution taught us we are more at risk of predators at night, therefore darkness puts our senses on high alert. Horror movies are dark. Vampires run amuck only in the darkest hours. We are taught to avoid dark alleys. Colors disappear and we can no longer rely on the one sense that gives us a wealth of information, sight. Unhampered by the stark reality of vision, our imagination takes over and sends us on the wildest of rides.

These are some of the negative connotations of darkness. Are there positive attributes?

Many people seek out the thrills of darkness. Dark restaurants, employing blind or visually impaired waiters, promise to heighten the sense of smell and taste, hyper emphasizing sound and texture.

Dark rides offer the pinnacle of immersive fantasy amusement.

That little black dress is endlessly flattering in all situations. Every woman reaches for it when faced with a wardrobe quandary. Black paints her with power, elegance, mystery, and sophistication.

A business that’s “in the black” is rolling in dough.

In Africa, black is the color of age and wisdom.

In ancient Egypt, black represented life and rebirth. The Bible opens thus, “In the beginning, God created the heavens and the earth. The earth was astonishingly empty, and darkness was on the face of the deep…” Darkness is a new world of endless possibility. A blank slate. A veritable playground for creation.

A baby is cradled in the darkness and safety of the womb. Darkness is safe, warm, and nourishing.

We make love under the cover of night. Darkness is sensual, emotional, and erotic.

Anna Steidle and Lioba Werth, published a study in 2013, in the Journal of Environmental Psychology, exploring the effects of lighting on creativity. They found that dim illumination improved creative performance. The perceived freedom gained from the relative anonymity of darkness loosed inhibitions and fostered heightened creativity. Darkness elicited a feeling of freedom from constraints and triggered a risky, explorative processing style. Subjects in a dimly lit room solved significantly more creative problems correctly than those in a brightly lit room. On the other hand, brightly lit workspaces were better for analytical tasks. Once you start crunching those numbers, shed some light on the problem.

What about emotion and lighting? An article in the Journal of Consumer Psychology, April 2014, suggests that turning down the lights reduces emotional volatility in decision-making. Bright lights create the illusion of heat and trigger the perception of aggression and sexiness in others.

A Young Singer, c.1640 by George de Latour

And what of art and darkness?

Artists have used darkness and the absence of color since time immemorial. Chiaroscuro is an artistic technique, developed during the Renaissance, that uses the strong contrast between light and dark to heighten dramatic effect.

Bacchus and Drinker; 1621 by Bartolomeo Manfredi

In 2015, the Petit Palais in Paris opened, “The Baroque Underworld: Vice and Destitution in Rome,” showcasing post-Caravaggio chiaroscuro painters, an exhibition of 70 mostly black paintings created in Rome in the first half of the 17th century, that made dramatic use of lighting. Almost all were decadent scenes of bawdiness, lewdness, and sensory excess: depiction of life under the cover of darkness.

 

Malevich painted his first Black Square in 1915, blurring the margins between darkness and perception, removing vision as our primary interaction with visual art, and thus pioneered the art of abstraction.

Black Square, 1915 by Kazimir Malevich

What has art to do with medicine, you ask? Abstraction is important. Knowing how to look at art, how to separate out each sense and analyze our interaction with a particular work, is crucial to the work of a good clinician. When the eye abandons itself into the gloom of the black abyss, the mind is untethered, constraints are lifted, our analytical skills can be freed from the bonds of conventional thinking.

One of my favorite quotes, from Edgar Allen Poe’s, The Raven, says it best,

“Deep into that darkness peering, long I stood there, wondering, fearing, doubting, dreaming dreams no mortal ever dreamed before.”

A study published in September of 2017 in Ophthalmology, demonstrated significant improvement in observational recognition skills among students who took an art observation course, and proved that art training alone – without a clinical component—could help teach medical students to become better clinical observers. Malevich said of his Black Square, “It is from zero, in zero, that the true movement of being begins.” Perhaps the darkness of our exam room allows us to zero out and hone our observational and intuitional skills.

We are all intimately familiar with how light and darkness interact with the human eye, but let’s review how it affects the human brain. Darkness stimulates the production of the hormone melatonin, from its precursor neurotransmitter, serotonin. Irregularities of melatonin production are linked to disruptions in the sleep cycle and Alzheimer’s. Higher melatonin levels improve memory, show strong neuroprotective activity, suppress breast and possibly other cancers, and protect against brain damage. One of the reasons we counsel patients to limit blue light emitting-devices towards evening is to allow the brain to use darkness to quiet down for regenerative sleep.

Let’s return for a moment to the concept of the womb.

From Plato’s allegory of the cave to Freud’s discussion of the proverbial desire to return to the womb, to Nabokov’s depictions of his childhood attempts to seek the shelter of the womb, as a society, we are both intrigued and obsessed by the dark, primordial space from whence we came.

The cradle rocks above an abyss, and common sense tells us that our existence is but a brief crack of light between two eternities of darkness,” writes Nabokov in his autobiographical work, Speak, Memory. Why the obsession? Perhaps that is a subject for another discussion, but for our purposes, suffice it to say that in the darkness before birth, the mind, and therefore the eye, is at it’s most impressionable. No image has yet been stamped on awareness, no visual memories formed, no neurological pathways laid down. We have not yet learned to see and so the possibilities for visual development are boundless.

The concept of forcing a “hard reset” of the brain and visual cortex, by returning the visual system to the proverbial womb, is by no means new. Darkness retreats are abundant all over the world and Tibetan Buddhists have long practiced meditation in total darkness for periods of days and even months, promising improved physical and spiritual health, opening of the “third eye,” and transforming unresolved karma.

A 2007 study (H.Y. He, B. Ray, K. Dennis, E.M. Quinlan) demonstrated that a period of time spent in total darkness restored cortical plasticity and lead to partial recovery of visual acuity in adult rats and a second study in 2013 (K.R. Duffy, D.E. Mitchell) demonstrated prolonged light deprivation to give rapid and complete recovery from amblyopia in cats. A 2016 study (Dake Li, Qi Fang, Hongbo Yu) showed a five-fold decrease in ERG b-waves in adult rats that were dark exposed for 24 hours, proving it possible to achieve a functional shift in the retinas of adult mammals, by prolonged deprivation of light.

Building on these studies and theories, Ben Backus and Elizabeth Quinlan of the University of Maryland, in collaboration with SUNY Optometry’s Cristina Llerena and Jose-Manuel Alonso, launched a fascinating study in 2012 to see if subjecting an adult to total darkness for a period of ten days could reset the visual system and restore it’s state of infantile plasticity. Calling themselves, “scotonauts,” from the Greek word for darkness, Dr. Backus and his research assistant, Morgan Williams, spent five days locked up in a specially outfitted apartment in Brooklyn, with food delivered through a “light-lock” ante-chamber. Interesting experiences ensued: they began to hallucinate, seeing vivid landscapes, building facades, and detailed interiors. Two days’ worth of dark adaptation excited the visual neuronal networks causing them to fire and form visual hallucinations. Emerging from their primordial cave after five days, the two scotonauts were incredibly light sensitive and perceived colors to be incredibly vibrant, but other than that, no harm was done, and they launched Project Luma to study the effects of prolonged light deprivation on the plasticity of the human visual system. Further news of this remarkable experiment is unavailable but the implications this has on treatment of amblyopia and post-traumatic vision loss, are enormous.

Let’s come back to the practical side of things.

A January 2018 New York Times article, titled, “Doctor, I’m Going Blind. Why Won’t You Talk to Me?” lamented the loss of empathy and bedside manner in the rush to fit 40-65 patients into one day’s schedule. The writer expressed her fear of vision loss and slow descent into darkness and her frustration at being unable to get any compassion or explanation from the busy doctor whose expertise she so desperately sought. She understood the pressures of modern medical practice and even showed concern for the doctor who could barely stop to take a lunch or bathroom break, but nonetheless, she was terrified and left un-reassured. No-one longs to be this doctor, no-one wants to be this patient, but the reality is stark. The population is booming, time and resources are scarce, and healthcare is rationed. Each clinician must find his or her own path to assuring that the needs of the many don’t always outweigh the needs of the few. To accomplish this feat, it is crucial first to admit that the problem exists, then to understand its nature, and finally to use knowledge and experience to creatively attain balance.

Picture this: you are ushered into a small, darkened room, offered a seat, asked intensely personal questions by a relative stranger. You read some letters on a wall, the stranger shines painfully bright lights into your eyes. You are then subjected to a weird rigamarole – some kind of forced-choice paradigm where you are asked to make split-second decisions which will ostensibly determine the way you see for the rest of the year, perhaps two, but that’s not all! Just when you thought the ordeal was over, what little light there was in the room disappears entirely, the stranger leans in almost like your beloved significant other on the verge of a kiss, and peers directly into your soul! All the while you are required to silently stare straight into something that feels pretty much like the sun. Didn’t your mother warn you about situations like this?

How then do we take all these concepts that govern the interactions between darkness, the psyche, the brain, and the eye, and use them to our advantage? Life experience dictates that when we learn new concepts and actively try to place them into practice, the learning curve may be steep but the result is a higher level of functioning. So take that same patient, usher them into the same darkened room, but now be aware that bright lighting reduces lying and confabulation and darkness increases our propensity to fib. Want clearer, more honest responses to the medical history intake? Turn up the lights. Need a reluctant or shy patient to be more frank? Dim the lights a bit and lean in, creating a more intimate space that lets them spill their innermost secrets with less inhibition. Of course, we need complete darkness to refract but remember, this heightens the patient’s fear and puts their senses on high alert. That’s ok – we want them alert and responsive to the subjective refraction, so keep the lights dim but speak in a clear and calm voice that keeps them alert but assuages their fear. Need to think about a complex case that just doesn’t seem to fit the usual patterns? Dim the room lights and unleash your creativity and explorative style. Hang a few good works of art on your walls and allow your vision to wander into a different dimension to increase clarity of reasoning. Need to work out the numbers on a complicated toric scleral lens fit? Crank the lighting – analytical skills are sharper in a brightly lit room. Need to hone your observational skills? Go to a few lectures at your local art museum and learn how to look at art with an analytical eye. Need to prompt a patient into making a rational decision about treatment options? Lower the lights to dampen emotional volatility. Finally, should the need arise to counsel a patient about imminent vision loss, be aware that the fear of the dark is paralyzing, oppressive, and real, but you have the power to lessen that apprehension by educating the patient with even the worst prognosis, about cultures that embrace the darkness through dark retreats, about joyful sensory experiences that purposely exclude vision, and about the possibility of opening the mind and senses through prolonged exposure to darkness.

As my namesake is a character in Twelfth Night, I cannot but end with,

“…there is no darkness but ignorance…”

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