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Ramsay N, McKee J, Al-Ani G, Stone J. How do I manage functional visual loss. Eye (Lond) 2024; 38:2257-2266. [PMID: 38778139 PMCID: PMC11306732 DOI: 10.1038/s41433-024-03126-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
Functional visual loss is a subtype of functional neurological disorder (FND) and is a common cause of visual impairment seen in both general and neuro-ophthalmological practice. Ophthalmologists can generally diagnose functional visual loss reasonably confidently but often find it harder to know what to say to the patient, how to approach, or even whether to attempt, treatment. There is little evidence-based treatment despite studies showing up to 60% of adults having impactful symptoms on long-term follow-up. The last 20 years has seen large changes in how we understand, approach, and manage FND more widely. In this article, we set out our practical approach to managing functional visual loss which includes : 1) Make a positive diagnosis based on investigations that demonstrate normal vision in the presence of subjectively impaired vision, not just because tests or ocular exam is normal; 2) Explain and label the condition with an emphasis on these positive diagnostic features, not reassurance; 3) Consider eye or brain comorbidities such as migraine, idiopathic intracranial hypertension or amblyopia; 4) Consider working with an orthoptist using diagnostic tests in a positive way to highlight the possibility of better vision; 5) Develop simple treatment strategies for photophobia; 6) Consider psychological factors and comorbidity as part of assessment and therapy, but keep a broader view of aetiology and don't use this to make a diagnosis; 7) Other treatment modalities including hypnotherapy, transcranial magnetic stimulation and more advanced forms of visual feedback are promising candidates for functional visual loss treatment in the future.
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Affiliation(s)
- Neil Ramsay
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Justin McKee
- Dept Ophthalmology, Royal Infirmary of Edinburgh and Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Gillian Al-Ani
- Dept Ophthalmology, Royal Infirmary of Edinburgh and Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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Lawlor M, Huynh B, Humphreys K, Ogunbowale L, Kopelman MD, Plant GT. Observational cohort study of 100 patients presenting with functional visual loss: clinical characteristics and comparison with other functional neurologic disorders. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00063-2. [PMID: 38580217 DOI: 10.1016/j.jcjo.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/27/2023] [Accepted: 02/25/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Recent research has helped to develop a more detailed understanding of many functional neurologic disorders. The aim of this study was to increase our knowledge of functional visual loss and to compare the findings with those of other functional syndromes. DESIGN Prospective and retrospective observational cohort study. METHODS This study took place at neuro-ophthalmology clinics at 3 major hospitals in London, United Kingdom, over a 12-month period. The study population consisted of 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. All participants had their diagnosis confirmed with a full neuro-ophthalmic examination, neuroimaging, and visual electrophysiology. A full assessment of all participants' medical history was obtained from their general practitioner, and all participants completed a series of questionnaires assessing relevant associations. RESULTS Data were obtained on 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. Participants with functional visual loss were typically female (74%) with a mean age at vision loss of 40.0 ± 16 years. Sixty-four percent of participants had bilateral vision loss; the remainder, unilateral loss. Twenty-six percent of the total cohort had organic visual loss with functional overlay. Fifty percent of participants with functional visual loss had a preexisting psychiatric diagnosis, the most common being a depressive disorder. Sixty-two percent of participants had an ocular history, and 87% had a previously diagnosed medical illness, most commonly neurologic (45%). Thirty-five percent of participants self-reported at least 1 additional functional symptom. CONCLUSIONS Our population of functional visual loss subjects shares many similarities with the majority of patients with other functional neurologic disorders. They are generally young and female and have a greater than expected rate of psychiatric, medical, and coexisting ocular conditions. We found increased rates of precipitating stressors, clinical depression, and organic eye problems in subjects with functional visual loss.
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Affiliation(s)
- Mitchell Lawlor
- Save Sight Institute, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia
| | - Brandon Huynh
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia.
| | - Kate Humphreys
- Cleveland Clinic London Hospital, London, United Kingdom; Department of Neuropsychiatry and Memory Disorders, St. Thomas Hospital, London, United Kingdom
| | - Lola Ogunbowale
- Department of Neuro-Ophthalmology, Moorfields Eye Hospital, London, United Kingdom
| | - Michael D Kopelman
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Gordon Terence Plant
- Department of Brain Repair and Rehabilitation, University College London, London, United Kingdom
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Tao BKL, Xie JS, Margolin E. Functional vision disorder: a review of diagnosis, management and costs. Br J Ophthalmol 2024:bjo-2023-324856. [PMID: 38307720 DOI: 10.1136/bjo-2023-324856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
Functional vision disorder (FVD) is a relatively common diagnosis in ophthalmic practice which can be difficult to make because of clinician's apprehension to miss organic pathology. We review the diagnostic approach to patients with FVD, organic mimics of FVD, its diagnostic and management strategies and associated cost burden. Patients with FVD typically present with visual acuity and/or field loss. Diagnostic work-up should include patient observation, detailed history, pupillary examination, dilated ophthalmoscopy, visual field testing and ganglion cell analysis of the macular complex. Most common organic mimickers of FVD are amblyopia, cortical blindness, retrobulbar optic neuritis, cone dystrophy and chiasmal tumours; however, all could be ruled out by structured diagnostic approach. For patients with unilateral visual loss, bottom-up refraction, fogging of the well-seeing eye in the phoropter, convex lens and base-down prism tests could aid in diagnosis. For patients claiming binocular vision loss, checking for eye movement during the mirror test or nystagmus elicited by an optokinetic drum can be helpful. Effective management of FVD involves reassurance, stress reduction and, if agreed on, management of comorbid anxiety and/or depression. The social cost of FVD is predominately economic as patients typically meet several healthcare providers over multiple visits and often undergo several neuroimaging studies before neuro-ophthalmology referral. Further, inappropriate granting of disability benefits confers additional stigma to patients with organic vision loss.
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Affiliation(s)
- Brendan Ka-Lok Tao
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jim Shenchu Xie
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Edward Margolin
- Department of Ophthalmology & Vision Science, University of Toronto, Toronto, Ontario, Canada
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Okrent Smolar AL, Ray HJ, Dattilo M, Bouthour W, Berman G, Peragallo JH, Kedar S, Pendley AM, Greene JG, Keadey MT, Wright DW, Bruce BB, Newman NJ, Biousse V. Neuro-ophthalmology Emergency Department and Inpatient Consultations at a Large Academic Referral Center. Ophthalmology 2023; 130:1304-1312. [PMID: 37544433 DOI: 10.1016/j.ophtha.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023] Open
Abstract
PURPOSE Prompt neuro-ophthalmology consultation prevents diagnostic errors and improves patient outcomes. The scarcity of neuro-ophthalmologists means that the increasing outpatient demand cannot be met, prompting many emergency department (ED) referrals by non-neuro-ophthalmologists. We describe our quaternary care institution's ED and inpatient neuro-ophthalmology consultation patterns and patient outcomes. DESIGN Prospective observational study. PARTICIPANTS Consecutive neuro-ophthalmology ED and inpatient consultation requests over 1 year. METHODS We collected patient demographics, distance traveled, insurance status, referring provider details, consultation question, final diagnosis, complexity of consultation, time of consultation, and need for outpatient follow-up. MAIN OUTCOME MEASURES Consultation patterns and diagnoses, complexity, and follow-up. RESULTS Of 494 consecutive adult ED and inpatient neuro-ophthalmology consultations requested over 1 year, 241 of 494 consultations (49%) occurred at night or during weekends. Of ED consultations (322 of 494 [65%]), 127 of 322 consultations (39%) occurred during weekdays, 126 of 322 consultations (39%) occurred on weeknights, and 69 of 322 consultations (22%) occurred on weekends or holidays. Of 322 ED consultations, 225 of 322 consultations (70%) were patients who initially sought treatment in the ED with a neuro-ophthalmic chief symptom. Of the 196 patients sent to the ED by a health care professional, 148 patients (148/196 [76%]) were referred by eye care specialists (74 optometrists and 74 ophthalmologists). The most common ED referral questions were for papilledema (75 of 322 [23%]) and vision loss (72 of 322 [22%]). A total of 219 of 322 patients (68%) received a final active neuro-ophthalmic diagnosis, 222 of 322 patients (69%) were cases of high or very high complexity, and 143 of 322 patients (44%) required admission. Inpatient consultations (n = 172) were requested most frequently by hospitalists, including neurologists (71 of 172 [41%]) and oncologists (20 of 172 [12%]) for vision loss (43 of 172 [25%]) and eye movement disorders (36 of 172 [21%]) and by neurosurgeons (58 of 172 [33%]) for examination for mass or a preoperative evaluation (19 of 172 [11%]). An active neuro-ophthalmic diagnosis was confirmed in 67% of patients (116 of 172). Outpatient neuro-ophthalmology follow-up was required for 291 of 494 patients (59%). CONCLUSIONS Neuro-ophthalmology consultations are critical to the diagnosis and management in the hospital setting. In the face of a critical shortage of neuro-ophthalmologists, this study highlights the need for technological and diagnostic aids for greater outpatient access. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | - Hetal J Ray
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Walid Bouthour
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Gabriele Berman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jason H Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Sachin Kedar
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Pendley
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - James G Greene
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Keadey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Beau B Bruce
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.
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