The document discusses the evaluation of patients with unexplained visual loss, outlining potential causes which include refractive, retinal, or optic nerve issues, as well as non-organic factors. It emphasizes the importance of thorough examination and testing methods such as color vision assessment and dark room pupillary responses to differentiate between organic and non-organic visual loss. Additionally, it highlights common misdiagnoses and the need for careful analysis in determining the underlying issues affecting vision.

1. Approach to the Patient with Unexplained Visual Loss
Mohamed Ahmed ELShafie
MD, HMS alumni

2. Where is the problem?
•REFRACTIVE /
MEDIA
•RETINA /
CHOROID
•OPTIC NERVE /
VISUAL
PATHWAY
•NONORGANIC

3. •irregular astigmatism
•oil-droplet cataracts
•occult corneal disease
Refractive / Media

4. Evaluation
•pinhole
•near vision
•retinoscopy/corneal topography
•direct ophthalmoscopy
•rigid contact lens over-refraction
•color vision

5. Neuro-op Secret
Weapon
Central visual loss from optic neuropathy causes decreased
color vision!
Color not affected by refraction, media, retinal disease
unless acuity < 20/200 (6/60).
•Hardy-Rand-Rittler - more sensitive
•Ishihara

6. •CC: 60-yr-old Dentist c/o gradual bilateral blurriness.
•PMH: hypertension
•Social: 1 vodka martini/day
•Dx: Tobacco-Alcohol Amblyopia
•Told to stop drinking

7. DX: Tobacco-Alcohol Optic
Neuropathy?
VA: 20/60 OU N: J2 OU
Color: 10/10 HRR OU
Pupils: moderate, no RAPD
VF: normal
Fundus: normal

8. Further Testing
•Direct Ophthalmoscopy: blurry view
•Repeat SLE: oil drop cataracts

9. •65-yo-WM c/o blurred vision “like when I had a retinal
detachment”. Drove home from cairo to be seen urgently.
Exam
20/20 OD, CF OS
No RAPD
Retina attached Fundus “normal”
Referred for possible optic neuropathy

10. •Exam normal, other than vision

11. During neuro exam notes that head
tilting improves vision?!

12. •pinhole, retinoscopy, corneal topography
•color vision, direct ophthalmoscopy
•rigid contact lens over-refraction
These are the easy ones!
But, they are often
missed.

13. Unexplained Visual Loss
•Refractive / Media
•Retina / Choroid
•Optic Nerve / Visual Pathway
•Nonorganic

14. History
•“distorted” “crooked” “broken-up” are terms used to
describe metamorphopsia, usually due to macular
disease.
•tiny central scotoma

15. Exam
•no or small RAPD
•Amsler grid

17. •57-yo-WF c/o peripheral vision loss after colonoscopy.
•PMH: HTN, lung cancer
•EXAM
VA: 20/25 (6/7.5) OU Color: NL
•Pupils: moderate, no RAPD
•SLE: rare ant vit cell OU

20. ERG Flat

21. Cancer Associated Retinopathy
(CAR)
•rapid visual loss (peripheral first)
•positive visual phenomenon
•ring scotomas early
•vitreal cell / retinal vascular attenuation
•ERG abnormal
•anti-recoverin antibodies

22. IF REFERRED BY
RETINAL SERVICE,
THE PROBLEM IS
ALWAYS RETINAL.

23. Unexplained Visual Loss
•Refractive / Media
•Retina / Choroid
•Optic Nerve / Visual Pathway
•Nonorganic

24. Relative Afferent Pupillary Defect(RAPD)
⇒critical, objective
⇒under-emphasized
•Dark room – Bright light
•2 eyes, >1 working pupil
•Pt: fix at distance

25. Secret Weapon!

26. Perimetri
c
Strategie
s

27. •75-yr-old WF c/o difficulty reading since yesterday.
•PMH: Hypertension
•EXAM
VA: 20/20 OU
N: J1+ OU
Color: NL
SLE: pcIOL OU
Fundus: scattered drusen

28. Humphrey 24-2

29. Humphrey 10-2
Left superior paracentral homonymous hemianopic
scotoma

31. •71-yr-old WM c/o difficulty reading x 4 months.
•Has seen 3 doctors and has 5(!) new pairs of glasses.
•Wife notes occasional clumsiness.
•EXAM
VA: 20/20 OU N: 20/20 OU
HVF 24-2 & 10-2: NL OU
Everything NL

32. Aphasia Examination

33. Visual Variant of Alzheimer’s Disease
•reading difficulties (90%)
•simultanagnosia (66%)
•spacial disorientation (56%)
•ocular apraxia (50%)
•homonymous VF defects (25%)

34. Unexplained Visual Loss
Cerebral & Optic Nerve Conclusions
•Did I miss a RAPD?
•Is color vision normal?
•Did I do the correct visual field?
•Is there diffuse cerebral dysfunction?

35. •Refractive / Media
•Retina / Choroid
•Optic Nerve / Visual Pathway
•Nonorganic
Unexplained Visual Loss

36. Nonorganic
•Malingering: secondary gain
•Munchausen: factitious,
intentional
•Conversion Disorder: psychiatric
•Hypochondriac: exaggerates

37. Common
presentatio
ns
1.Unilateral/Asymmetric visual acuity
2.Bilateral visual acuity
3.“Tunnel” vision
4.Unilateral temporal hemifield
Beware non-organic overlay!

38. 1.
Unilateral
Vision
Loss
•start with tiny letters
•DKR – “doctor killing refraction”
•gradual fogging in phoropter
•stereopsis – for decreased near vision
•vertical prism test

39. Vertical Prism Test
simple & quick

40. sees 1 letter – look for etiology of visual loss
organic
sees 2 letters – you got ‘em!
nonorganic

41. •28-yr-old WF c/o poor vision OS after being kicked in eye.
•POH: HLA B27+ uveitis, h/o macular edema.
• best corrected VA 20/40
•EXAM
VA: 20/40 OD, CF OS
Pupil: no RAPD
SLE/Fundus: NL

42. Our patient 20/40 OD, Count fingers
OS
She saw 2 letters

43. •46-yr-old WM c/o blurry vision OU for 2
months.
Referring notes pt looking at small pocket
calendar suspects nonorganic visual loss.
•EXAM
VA: 20/60 OD, 20/200 OS
Pupils: no RAPD
SLE/Fundus: nl

45. Vertical
Prism Test
He saw 1 letter

46. Focal ERG shows abnormal macular response

47. 1.Unilateral/Asymmetric visual
acuity
2.Bilateral visual acuity
3.“Tunnel” vision
4.Unilateral temporal hemifield

48. 2. Bilateral Vision Loss
•observe ambulation
•sunglasses – red flag
•OKN drum

49. 1.Unilateral/Asymmetric visual acuity
2.Bilateral visual acuity
3.“Tunnel” vision
4.Unilateral temporal hemifield

50. •31-yr-old woman c/o tunnel vision x 1
month
•EXAM
VA: 20/20 OU
Pupils: no RAPD
SLE/Fundus: nl

53. 1.Unilateral/Asymmetric visual acuity
2.Bilateral visual acuity
3.“Tunnel” vision
4.Unilateral temporal hemifield

55. •Both eyes open

56. •60-yr-old BM c/o of poor vision since childhood, no changes noted.
•PMH: HTN
•Social: recently released from prison after 25 yrs
•EXAM:
VA: HM OU Pupils: brisk, no RAPD
VF: sees motion in all quadrants
Fundi/ERG: NL

57. •OKN drum: nystagmus

58. Unexplained Visual Loss
Summary
1.Where is the problem?
2.Use common tools: color vision, direct ophthalmoscopy
3.Get the correct visual field test.
4.Prove nonorganic! (vertical prism test)