Psychogenic Visual Loss

  • Patient denies sight yet examination strongly suggests that sight is intact
  • Can be monocular or binocular, transient or persistent, central or peripheral, acute or chronic
  • May be psychiatric or behavioral disturbance (anxiety, depression, somatoform disorder, hypochondriasis, conversion, malingering)
  • Common in children who aim for attention or to avoid stresses
  • Often isolated deficit
  • May be difficult to distinguish from organic visual loss
  • Sometimes psychogenic and organic visual loss coexist ("embellishment")
  • Most commonly as persistent monocular profound visual loss
  • Less commonly as homonymous hemianopia, bitemporal hemianopia, monocular temporal hemianopia
  • Clues to psychogenic nature of visual loss are vague history of onset, inconsistent or bizarre responses on vision testing, normal pupil function and ocular structures, known psychiatric or behavior disorder
  • Malingerers aim for gain—compensation, relief from work or other obligations
  • Somatizers aim to resolve depression, psychosocial conflicts or predicaments
  • Hypochondriacs convinced they are ill
  • Conversion hysterics trying to avoid deep psychic issues
  • Organic visual loss, which can be difficult to exclude
  • Refer to ophthalmologist who should have skills and tricks to unmask this condition
  • If issue can be identified and resolved, symptom often resolves
  • Malingerers often hold fast and may be confrontative and even dangerous
  • Underlying issues in children usually easier to identify, although abuse must be excluded