The prognosis of patients with hysterical visual impairment

Functional vision disorders in adults: a paradigm and nomenclature shift for ophthalmology

Vision loss with clinical findings that are incompatible with the symptoms and recognized neurological or ophthalmic conditions is a common presentation of patients to neurologists, ophthalmologists, and neuro-ophthalmologists. The accepted terminology to describe such patients has evolved over time, including functional visual disorder (FVD), non-organic vision loss, non-physiologic vision loss, functional vision loss, psychogenic, psychosomatic, and medically unexplained visual loss. Likewise, attitudes and recommended management options have changed over the years in the fields of psychiatry and neurology. FVD is a diagnosis of inclusion, and it is critical that the diagnosis be made and delivered efficiently and effectively to reduce patient and physician duress. We review the current Diagnostic and Statistical Manual (DSM V) terminology and the prior literature on FVD and describe how the approaches to diagnosis and management have changed. We provide recommendations on the appropriate techniques and diagnostic approach for patients with FVD. We also propose a protocol for consistent and standardized discussion with the patient of the diagnosis of FVD. We believe that the adoption of FVD as both a paradigm and nomenclature shift in ophthalmology will improve patient care.

Seeing again: treatment of functional visual loss

There is very little published literature on treatment strategies for functional visual loss. We present two people with long duration of functional visual loss who achieved complete recovery with a novel combination of therapeutic approaches. These included: (1) the clinician being transparent regarding positive signs such as optokinetic nystagmus, in order to persuade family members of the diagnosis, (2) regularly positively acknowledging everyday events that indicated visual ability, (3) using occipital transcranial magnetic stimulation to induce phosphenes as an artificial temporary visual experience and (4) using hypnotherapy to promote visual recovery. We discuss these individual therapeutic approaches in further detail including their background and rationale and include patients' reflection on their treatment experiences.

[Testing and approach when non-organic visual loss is suspected]

Approximately 5% of the patients in the ophthalmological practice suffer from non-organic vision loss. In children non-organic vision loss has been observed from the age of 6 years. In order to be able to make a rapid diagnosis knowledge of the relevant clinical tests is decisive. If a patient shows signs of non-organic visual loss, diagnostic externalization of the visual function is crucial. Depending on the symptoms there are various tests, which can be used to differentiate between organic and non-organic disorders. For therapeutic and economic reasons an early diagnosis of a non-organic visual loss is crucial. Ophthalmologists need to differentiate between malingering and augmentation, where the patient is aware of the fraud and tries to gain personal benefit from it, and somatoform disorders. In the latter, a more sensitive approach is recommended.

An atypical presentation of functional visual loss: A case report

RATIONALE

Functional visual loss (FVL) can manifest as various symptoms. Decreased distant visual acuity is the most common symptom and visual field defect is the second most common symptom. Hemianopsia is rarely reported. In an atypical situation of FVL, it is important to prove that no organic pathology exists, through detailed history taking and appropriate examinations.

PATIENT CONCERNS

This review presents the case of a 48-year-old male patient presented with decreased bilateral visual acuity and visual field defect after a traffic accident 3 weeks ago. Visual field test showed atypical features of FVL in which visual field change from binasal hemianopsia to left homonymous hemianopsia.

DIAGNOSIS

The best corrected visual acuities (BCVA) were 20/63 in both eyes and binasal hemianopsia was observed on a Humphrey visual field test. Brain computed tomography (CT) scan and magnetic resonance imaging (MRI) showed no abnormalities in the brain and optic chiasm. Two weeks after presentation, however, the patient's visual field defect changed from binasal hemianopsia to left homonymous hemianopsia. We diagnosed it as FVL due to conversion disorder.

INTERVENTION AND OUTCOMES

We decided to cooperate with a psychiatrist for cognitive behavioral therapy and the patient is under observation.

LESSONS

Binasal hemianopsia and homonymous hemianopsia are rare; however, it may occur simultaneously in 1 patient with FVL. The possibility of FVL should be considered when there is atypical visual field defect and no organic abnormalities are observed. Repeated Humphrey field test and VEP may be helpful in diagnosis of FVL.

Postoperative transient blindness after general anesthesia and surgery: case report of conversion disorder

Postoperative acute visual loss due to organic pathology has been described after spinal surgery in the prone position. This report describes a case of transient postoperative blindness in a patient after general anesthesia and surgery in the prone position. Postoperative workup did not reveal any organic pathology. Unbeknown to the treating physicians, the patient had a comorbid untreated psychiatric history. Upon psychiatric consultation, the patient was diagnosed with conversion disorder as a cause of postoperative blindness. There was full recovery of vision after psychiatric intervention within a week.

Prognosis of functional neurologic disorders

The prognosis of functional (psychogenic) neurologic disorders is important in being able to help answer patients' and carers' questions, determine whether treatment is worthwhile, and to find out which factors predict outcome. We reviewed data on prognosis of functional neurologic disorders from two systematic reviews on functional motor disorders and dissociative (nonepileptic) seizures as well as additional studies on functional visual and sensory symptoms. Methodologic problems include heterogeneity in studied samples and outcome measures, diagnostic suspicion and referral bias, small size and retrospective design of available studies, possible treatments during follow-up, and literature review bias. With these caveats, the prognosis of functional neurologic disorders does appear to be generally unfavorable. In most studies, functional motor symptoms and psychogenic nonepileptic attacks remain the same or are worse in the majority of patients at follow-up. Measures of quality of life and working status were often poor at follow-up. Frequency of misdiagnosis at follow-up was as low as other neurologic and psychiatric disorders. Long duration of symptoms was the most distinct negative predictor. Early diagnosis and young age seem to predict good outcome. Emotional disorders and personality disorders were inconsistent predictors. Litigation and state benefits were found to be negative predictors in some studies, but others found they did not influence outcome.

Nonorganic (psychogenic) visual loss in children: a retrospective series

BACKGROUND

Few studies provide follow-up information or systematic investigation of prognostic parameters of nonorganic (psychogenic) visual loss in children.

METHODS

A retrospective case series analysis was performed on 58 patients younger than 16 years old who had nonorganic visual loss and underwent at least a 3-month follow-up clinic visit and/or telephone interview between 1992 and 2007 at a single institution in Italy. All patients underwent a full neurologic, ophthalmologic, and orthoptic evaluation. Visual electrophysiologic tests were performed in many patients as part of the evaluation. Neuroimaging was performed and psychiatric referral was made only as needed. We collected data on the age at onset, time to diagnosis of nonorganic visual loss, type and duration of visual symptoms, and concomitant psychologic or psychosocial difficulties.

RESULTS

Visual deficits consisted mostly of reduced visual acuity (76%) and visual field defects (48%). The diagnosis of nonorganic visual loss could be reached with confidence by means of observing inconsistent performance on a wide array of visual function tests, and, in doubtful cases, by means of electrophysiologic investigations. The mean time from onset to diagnosis was 3.1 months. The mean duration of visual symptoms from reported onset to disappearance was 7.4 months. Complete resolution of all visual symptoms occurred in 93% of patients and did so within 12 months of diagnosis in 85% of patients. There was no correlation between the duration of visual symptoms and age at onset, sex, time to diagnosis, type of ocular symptoms, or presence of psychosocial or psychologic difficulties.

CONCLUSIONS

Our study extends the follow-up information and confirms the findings of previous investigators in showing that nonorganic visual loss in children generally resolves spontaneously within 1 year and that no major psychiatric disorders are present or will appear after diagnosis. However, psychosocial stressors are often present and may predispose to this manifestation. There are no obvious predictors of rate of recovery.

Practical clinical approaches to functional visual loss

Functional visual loss (FVL) refers to subnormal vision or altered visual fields where no underlying pathology of the visual system can be found. It may be seen in a continuum from frank malingering to hysteria. FVL may first present to the general practitioner or physician and the financial burden of evaluation and potential disability-related claims may be substantial. Diagnosis relies on a high index of suspicion and demonstration with a few simple tests that the patient has better vision than alleged. The aim of this review is to provide a practical approach to examination of patients with suspected functional visual loss. An accurate and early diagnosis of FVL starts with a high index of suspicion. Only a few of the tests need to be learned well, performed smoothly and confidently. These clinical tests obviate the need to perform expensive imaging such as magnetic resonance imaging and if used in the correct setting have the potential to reduce further the cost of diagnosis. Management requires an understanding approach and confrontation is seldom helpful. It is important to stress to the patient that FVL has a good prognosis, thereby providing "a way out" and giving the patient the opportunity to recover.

Non-organic visual loss

Visual complaints without a physical basis are not uncommon presentations to the general physician, the neurologist, or the ophthalmologist. These alleged visual disturbances may be psychogenic or feigned. The diagnosis is made when all possible contributory pathology of the visual system is excluded, and reassurance remains the cornerstone of management.

Somatisation in neurological practice

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Visual impairment in hysteria

We have reviewed the charts of 45 neuro-ophthamological patients diagnosed with 79 monocular visual field or visual acuity losses secondary to non-organic etiology. Our aim was to determine the percentage of patients that have improvement in vision. As part of the protocol, all patients had magnetic resonance images, pattern visual evoked potentials, and flash electroretinography in addition to complete neuro-ophthalmological examinations. A single physician performed both the initial and follow-up examinations of all patients. Thirty-three percent of these patients had visual field defects only, 62% had both visual field defects and visual acuity defects, and 5% had only visual acuity defects. After organic disease was ruled out, all were given a timetable for recovery and clear reassurance regarding their prognoses for visual recovery. Seventy-eight percent of these patients showed improvement or were normal, while 22% showed no improvement. Younger patients without obvious psychiatric disorder had better prognoses than older patients.