Vision loss

Introduction


Visual • how the eyes and visual
system function
function
Functiona • available vision for daily living
l activities
vision
 Functional vision loss


Loss of
visual
Loss of field
visual
acuity
Medically
unexplained
vision loss1
1. Griffiths PG, Eddyshaw D. Medically
unexplained visual loss in adult patients.
 Symptoms
Light

sensitivity

Ocular Blurred or
Blepharospasm discomfort/
pain decreased
vision

Color vision
loss

Villegas RB, Ilsen P. Functional vision loss: a diagnosis of exclusion. Optometry. 2007;78:523-
533
 Triggers

 poor medical knowledge


 low socioeconomic status

 lack of concern for one’s situation

 mild injury

 psychological events

 Existing health condition

Heruti RJ, Levy A, Adunski A, Ohry A. Conversion motor paralysis disorder: overview and rehabilitation. Spinal
Cord. 2002;40:327- 334
 Manifestations


 Reduced visual acuity
 To blur
 To blindness

 Reduced field loss

 Tunnel vision
 Homonymous hemianopia

Villegas RB, Ilsen P. Functional vision loss: a diagnosis of exclusion. Optometry. 2007;78:523-
533
 Laterality


 Unilateral

 Bilateral

Villegas RB, Ilsen P. Functional vision loss: a diagnosis of exclusion. Optometry. 2007;78:523-
533
 Types of functional vision loss

Deliberate
Worrying
Imposter
 Impressionable Suggestible
Exaggerator Innocent
malingerer
Knowingly
exaggerating Thinks  Convince
Visual something d self Of a
• Faking of
symptoms wrong with vision
visual
 has a eyes problem
problem
serious wants to Very
problem help the doctor complacent
 monetary
 Doesn’t and make – not very
gain
want problem the symptoms Worried
(lawsuits)
to be easy to about
 attention
overlooked recognize problem
/ Miss out

Thompson HS. Functional Visual Loss. Amer J Ophthalmol. 1985;100:209- 13

 Associated diagnoses

 Anxiety and Depression(1)


 Panic attacks

 Fibromyalgia

 Psychiatric disorders in up to 50%

 Conversion disorder
1.Lim SA, Siakowski RM, Farris BK. Functional visual loss in adults and children. Patient
characteristics, management, and outcomes. Ophthalmology. 2005;112:1821-1828
 Organic conditions masking functional
vision loss
Starg

 macular
ardt
dystrophy
s
Leber’s
Multiple
congenital
sclerosis
Retinitis amaurosis

pigment
osa Oculocutan
Retrobulbar
eous
neuritis albinism
Foveal
hypoplasia

Bruce BB, Newman NJ. Functional visual loss. Neurol Clin. 2010 August;28(3):789-802
Importance of functional vision assessment


 To determine the current level of visual functioning in a
real environment while performing routine tasks

 To make appropriate device recommendations and

environmental modifications that may increase visual
functioning

 To develop instructional goals and strategies

Functional vision assessment

Non visual tasks 

• Medical/Visual history

History •
•
Education/Rehabilitation history
Daily Routine
• Chief Complaint

• Illumination
Environment •
•
Contrast
Visual complexity
• Safety

General eye examination

 Tests to rule out organic involvement

Visual acuity (1)


•
Visual fields •
Central
Peripheral

• Eye alignment
Ocular motility •
•
Fixation
Convergence
• Saccades and pursuits

Color perception

1. Colenbrander A. Measuring Vision and Vision Loss. Vol. 5, Ch. 51 in Duane’s Clinical Ophthalmology, Tasman,
Jaeger eds., Lippincot Williams and Wilkins, 2002 edition
Tests to rule out organic involvement


Contrast sensitivity

Stereopsis

Electrophysiological Tests

Neuroimaging
Functional vision loss assessment in infants
and toddlers

 Observation

 Appearance of the eyes

 Responses

 Perceptions
 
Functional vision loss ?

OR

Malingerers ??
 Cause for suspicion of functional vision
loss

 Fluctuations in best corrected visual acuity / visual field

 Lack of RAPD with unilateral or asymmetrical vision loss

 Visual field loss does not match optic disc appearance

 Suspicious visual field findings as cloverleaf pattern

 Tests to rule out malingering


 activities in the waiting room the way he is looking at
his watch, watching tv, phone, texting

 Observation of careful application of makeup,

carefully
dressed etc

 Bumping into objects

 Signature
 Tests to rule out malingering


 taking vision from bottom to top of the chart

 optokinetic nystagmus test

 Mirror test (pursuit movements)

 Menace reflex
 Vision assessment in suspicious cases


 Fogging (magic glass test)

 10 PD base down test

 10 PD base out Test

 Snellen’s colored chart with Red green goggles


 Questions for children


 Is the child browsing in the optical prior to examination?

 Does the parent think the child has a visual problem, or

suspect an ulterior motive?

 Does the parent notice the child squinting, covering an eye,

sitting close to the television, etc.?

 Is the child performing well in school?

 Did a sibling, friend or parent recently get a new pair

of glasses?
 Questions for adults


 Does the patient seem to have a known motive such
as a pending lawsuit, disability claim, etc.?

 Did the patient drive to the exam?

 Asking a simple question such as “what time it is” if

he or she is wearing a watch, or “what color are my
eyes?”

 Does the problem exist at both distance and near?

 Management


 Reassurance / Psychological counseling

 emotional support for the family, requests for special needs

at school

 Eye drops or glasses

 consistent follow up for frequent no-shows

 Kathol RG, Cox TA, Corbett JJ, Thompson HS. Functional visual loss. Followup of 42 cases. Arch
Ophthalmol1983;101(5):72935
 Kathol RG, Cox TA, Corbett JJ, Thompson HS. Functional visual loss. Followup of 42 cases. Arch Ophthalmol
1983;101(5):72935
 Thompson HS. Functional visual loss. Am J Ophthalmol 1985;100(1):20913
 At a glance…


 Functional vision loss – never caused by organic lesion

 Associated decrease in visual acuity or visual field

 Commonly associated with concurrent diagnoses of

depression, anxiety, panic attacks, fibromyalgia and
psychiatric disorders

 Careful history, examination with perfect questionnaires

to be asked for FVL assessment

 Reassurance