Seeing again: treatment of functional visual loss

Abstract

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.

Management of functional neurological disorder

“…There is very little evidence on specific treatment strategies for these conditions, and thus it is recommended to apply general principles of management and provide specific treatment for comorbid symptoms. There is a report in two patients with functional visual loss of the successful use of occipital TMS to produce flashes of light in patients' visual fields, as well as for supplemental hypnotherapy [34]. Large-field repetitive TMS over the centro-parietal area has been described for treatment of functional somatosensory symptoms in a case series of 12 patients, with a complete recovery observed in 6 patients and partial recovery in 3 patients [35].…”

How do ophthalmologists manage functional visual symptoms? A UK survey of ophthalmologists’ experience

“…Though few longitudinal studies measuring outcomes have been conducted, significant disability and enduring symptoms have been reported in up to 60% of patients with functional visual loss [11,12]. Case series have described individual therapeutic approaches for patients with functional visual loss [13]; however, the efficacy of these interventions remains unclear, and the recovery rate has been reported to be as low as 25% [12].…”

Neurostimulation for the treatment of functional neurological disorder: A systematic review

“… Sustained improvement in all scales one week after treatment and functional seizures remission 2 weeks after treatment. Yeo et al [64] Visual loss Case report 2 Central occipital cortex rTMS 10Hz 10 trains 10 sec trains Not specified “increasing amplitude until phosphenes and tolerance of facial twitching” Not specified [1000 pulses by TMS parameters] Case 1: 3 sessions over 3 months Case 2: 6 sessions over 1 year (frequency not specified) None reported Improvement in sight in both cases Complete recovery at 12 (sudden recovery after 8 months) and 15 months in each case (improvement attributed to head injury) . Portaro et al [67] Flaccid paraparesis Case report 1 MCBilateral (hand+leg area) rTMS 1Hz 100% maximum output 100 pulses 36 sessions in 12 weeks Psychological evaluation Gait analysis Improvement in mood, weakness, pain and gait immediately after rTMS.…”

“…There were two studies on other FND phenotypes: one case report that described a case of aphonia, which targeted the left prefrontal cortex and right motor cortex with an inhibitory protocol [59] and another report with 2 cases of visual loss, which stimulated (excitatory rTMS) the central occipital cortex [64] .…”