Medically Unexplained Visual Loss

ADULTS

 1 in 4 of all GP referrals are psychological

 1 in 3 of all neurology referrals are non-organic
 Ophthalmology-really rare

 Unusual referral letter?

 TOP TIP-read the notes before calling patient in including very old entries from years
ago.

 Diagnosis of ME/chronic fatigue syndrome is common in this group of patients

 Undiagnosed with MS
 Non-Epileptic Attack Disorder
 Functional disorder affecting other systems-in a wheelchair but not clear why-ask
 Chronic pain without good explanation
 History of anxiety or depression
 Multiple surgeries on different bits of anatomy none of which ever discovered any
pathology or helped much
 Paramedical career
 YOUR SENSES SHOULD NOW BE ALERTED THAT…ALL IS NOT AS IT SEEMS

 1) You have missed the real diagnosis

 2) Munchhausen’s
 3) Hypochondriac (Anxiety)
 4) Malingering
 5) Conversion disorder (hysterical)

 You have missed the real diagnosis

Things i have missed:

 Early Keratoconus
 Posterior Cortical Atrophy
Things referred to me as MUVL most often:
 Early Cataract

 Early posterior cortical cataracts can cause significant visual loss- Always
transilluminate the lens and look for keratoconus

If vision improves with pinhole, consider corneal topography, need for glasses or
just…… sclerosis
I see a lot of presbyopes in denial as…need to wear glasses

How not to miss Organic pathology?

 Take a history
 Examine the patient yourself
 Ishihara, RAPD, Reading vision N5
 Do a field
 Do an OCT macula and RNFL
 Look at OCT carefully especially Ellipsoid zone
 May need to do an MRI

OCT

Always worry you are missing organic disease when…

 Vision consistently and progressively gets worse
 There is no clue from the previous notes
 There is no underlying stress or second gain

 Bring patient back and re-examine?

 May need MRI

 If still not sure consider-

 Autofluorescence, FFA, ICG, Electrophysiolo…experience is that it is rare for these to
be us…normal in Adults

Medically unexplained visual loss

(MUVL)
 Munchausen’s (Factitious Disorder)
 Deliberately simulating illness (they like the role of being the patient)
 This is rare.
 Clues?

 Fat notes
 Easily faked conditions such as unexpected abdominal pain, blood in urine, nume…,
numerous operations which haven’t…

Munchausens
 Often present out of hours at the weekend when they get seen by junior person who
ends up admitting them
 Typically have ‘all’ the features of a complex condition in the history they give and
tell you they have been diagnosed with it elsewhere-for example Behce…

Munchausens
 Imperative to get old notes from the other hospital that diagnosed them
 They usually disappear when they realise you have rumbled them

Hypochondriac/Anxiety-
 Strong belief they have a serious diagnosis which has not yet has been made.
Excessive reporting of symptoms.
 Hypochondriac
 I have blurred vision
 And i have an ache behind my eyes
 And i get episodes of double vision lasting a few seconds
 And sometimes i get twitching in my right lower eyelid
 And sometimes my lids droop (produces photo showing no discernible droop)
 And my lids puff up terribly (produces photo showing normal lids) “There its more
obvious in this…
 It isn’t
 “I only came to see you because i was told…isn’t me that’s wasting your time its
someone…

Often they were completely fine until they went for a routine eye test and an optometrist
said something which implanted a seed of anxiety about going blind

The vision is often worse by the time they attend appointment

They don’t want to let people down by having nothing wrong with them

They need reassurance not more tests

Some patients just want reassurance that everything is normal and will be delighted when
told and will breathe audible sigh of relief and leave happy

They can be scared senseless if you order a “reassuring” MRI of head and won’t sleep for 6
weeks until scan has been reported ( are you reassuring yourself)

The inner consultation

ICE- we need to explore the patienta”
Ideas
Concerns
Expectations