Neuro-Ophthalmologic Manifestations of Psychogenic Disease

Abstract

From a neuro-ophthalmologic standpoint, five areas may be affected by psychogenic disease: (1) vision, including visual acuity and visual field; (2) ocular motility and alignment; (3) pupillary size and reactivity; (4) eyelid position and function; and (5) corneal and facial sensation. The physician faced with a patient complaining of decreased vision or some other disturbance related to the afferent or efferent visual systems for which there is no apparent biologic explanation has three responsibilities. First, the physician must ascertain that an organic disorder is not present. Second, the physician should induce the patient to see or do something that would not be possible if the condition were organic in nature. Finally, the physician should attempt to determine whether the patient has an underlying psychiatric disease or is experiencing psychosocial stress. In this article, manifestations of psychogenic disease as they pertain to vision are considered, and, where appropriate, the various methods used to diagnose and treat these phenomena are discussed.

A Benign Syndrome of Transient Loss of Accommodation in Young Patients

“…18,19 This may be an appropriate explanation of the complete symmetry of the disease between 2 eyes in this case series, though psychogenic problems were not encountered in these 5 patients. Malingering, as 1 variety of a functional visual failure, does not appear to be the preferential alternative to be considered here; unquestionably, the patients (most of them children) were not expected to know and be able to imitate so perfectly the rules of optics as revealed by their examination (ie, improvement of their visual acuity when reading distance was increased, failure to overcome a negative sphere lens for distant vision, and normal near vision with the near correction).…”

Practical clinical approaches to functional visual loss

“…If the eye moves with the drum/ tie, this suggest either a bilateral occipital cortical blindness or the patient is seeing and a functional component has been established. 15 Lastly, the pupil reflex is the only objective way to assess the afferent visual pathway. The pupillary reaction relies on the afferent pathway from the retina to optic nerve, crossing over at the optic chiasm to the optic tract which contains bilateral afferent fibers, deviating from the lateral geniculate nucleus to the pretectal nuclei in the midbrain.…”

“…A normal pupillary response in a patient who claims bilateral visual loss suggests bilateral symmetrical visual pathway pathology, such that afferent input is reduced bilaterally, or the patient is cerebrally blind such as from bilateral occipital disease, or there is a functional cause for visual loss. 15,18 Tests utilizing shock value are designed to elicit surprise in response to a visual cue. For instance, the menace reflex is when the examiner presents visual threats such as closed fist to the eye and observes for blinking or flinching.…”

“…The condition may be considered in isolation in terms of the visual afferent and efferent pathway; [15][16][17] however, more commonly, the clinician is faced with a variety of symptoms including binocular visual loss, monocular visual loss or monocular decrease in vision. The approach to each of these three categories is discussed.…”

Distance doubling visual acuity test: A reliable test for nonorganic visual loss

“…Unilateral nonorganic visual loss is best detected by well-known tests requiring good binocular vision or tests based on blurring or occluding the better eye without the patient's knowledge [4][5][6]. As in unilateral blindness, the absence of a relative afferent pupillary defect may indicate nonorganic decreased vision.…”