Nonorganic ophthalmic disorders can occur in children or adults and are diagnosed after the clinician determines that there is no physiologic or organic basis for the patient’s symptoms. A diagnosis of nonorganic vision loss is not a diagnosis of exclusion but rather an active diagnosis that requires confirmatory findings.
The first step in identifying a patient with a nonorganic disorder is to have a high index of suspicion when the patient’s pattern of vision loss does not fit the common sequence of known diseases. For example, trivial external trauma to the eye should not cause long-term disabling vision loss. Potential secondary gain factors may become evident as the examiner records the patient’s history. Some patients may be more focused on impending litigation or disability determination than on the diagnosis or treatment of their complaint.
“Everything counts” should be the clinician’s guiding principle. Each piece of information about the patient, from the time the appointment is made through completion of the office visit, may help direct the examination. For example, patients wearing sunglasses to their appointments were found to be more likely to have nonorganic vision loss. The patient’s general behavior and ocular capabilities should be observed throughout the examination. Can the patient successfully walk into the room and take a seat in a chair or shake the physician’s silently outstretched hand? Does the patient appear to have difficulty with nonvisual tasks such as signing in at the front desk? Displaying empathy, employing active listening, and carefully recording the patient’s story help the clinician to ensure that the doctor-patient relationship remains productive and nonconfrontational.
Suspicion should increase if the ophthalmic examination demonstrates a mismatch between objective and subjective findings. Examiners must be patient, persistent, and confident with the tests being used. The examiner can use misdirection to encourage a patient’s belief that a particular eye or function being tested is part of a normal eye examination, when in reality the examiner may be working to confirm a nonorganic disorder by demonstrating a nonphysiologic response, improved visual acuity, visual fields, or ocular motility.
A diagnosis of a nonorganic component can be confirmed when the patient does something that should not be possible based on the stated symptoms. Some tests may yield results that suggest the patient is not cooperating but do not prove a nonorganic disorder. The examination must be tailored to the individual and the specific concerns.
Although the scope and economic impact of nonorganic ophthalmic disorders are difficult to measure, somatic manifestations of psychogenic origin may account for at least 10% of patient visits to family physicians. The cost to society from nonorganic ophthalmic disturbances is enormous.
Bengtzen R, Woodward M, Lynn MJ, Newman NJ, Biousse V. The “sunglasses sign” predicts nonorganic visual loss in neuro-ophthalmologic practice. Neurology. 2008;70(3):218–221.
Bose S. Nonorganic Visual Disorders. In: Albert DM, Miller JW, eds. Albert & Jakobiec’s Principles and Practice of Ophthalmology. 3rd ed. Philadelphia: Saunders/Elsevier; 2008: 4017–4028.
Miller NR, Subramanian P, Patel VR, eds. Neuro-ophthalmologic manifestations of non-organic disease. In: Walsh and Hoyt’s Clinical Neuro-ophthalmology: The Essentials. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 2016;451–464.
Toldo I, Pinello L, Suppiej A, et al. Nonorganic (psychogenic) visual loss in children: a retrospective series. J Neuroophthalmol. 2010;30(1):26–30.
Excerpted from BCSC 2020-2021 series: Section 5 - Neuro-Ophthalmology. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.