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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 59  |  Issue : 1  |  Page : 83-84

Psychogenic blindness as a rare cause of presumed vision loss


Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission19-Aug-2020
Date of Acceptance01-Jan-2021
Date of Web Publication27-Mar-2021

Correspondence Address:
Dr. Sandra C Ganesh
Aravind Eye Hospital, Avinashi Road, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_118_20

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  Abstract 


A 12-year-old girl presented with unilateral, sudden painless loss of vision for the past 2 days. Ocular examination was normal. Optical coherence tomography, visually evoked potential, and magnetic resonance imaging of the brain and orbits were normal. With no organic cause found for vision loss, psychiatrist opinion was sought. After evaluation, she was diagnosed to have psychogenic blindness and treated with psychotherapy. When findings are inconsistent and no organic etiology can be diagnosed for the vision loss, psychogenic blindness is suspected and prompt referral to a psychiatrist is essential for complete recovery.

Keywords: Malingering, nonorganic vision loss, psychogenic blindness, sudden loss of vision


How to cite this article:
Ganesh SC, Narayanasamy V, Thaliath LP, Rao SG. Psychogenic blindness as a rare cause of presumed vision loss. TNOA J Ophthalmic Sci Res 2021;59:83-4

How to cite this URL:
Ganesh SC, Narayanasamy V, Thaliath LP, Rao SG. Psychogenic blindness as a rare cause of presumed vision loss. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 May 6];59:83-4. Available from: https://www.tnoajosr.com/text.asp?2021/59/1/83/312274




  Introduction Top


Nonorganic visual loss is one of the more perplexing conditions presenting to the ophthalmologist, and it is difficult to determine whether etiology of visual impairment is organic or functional. Organic etiology can be discarded only after conducting exhaustive investigations and essential neurological tests. Psychogenic blindness is a rare cause of nonorganic vision loss, and should be differentiated from malingering.

We report the case of a 12-year-old child who presented to us with psychogenic blindness and recovered following psychotherapy.


  Case Report Top


A 12-year-old girl presented at pediatric ophthalmology department with complaints of sudden, painless loss of vision in her left eye for the past 2 days. She gave a prior history of syncopal attacks, abnormal limb movements, and anxiety after having seen a “dark apparition” while returning at night with her friends from a religious school. She was treated with native medication for the above symptoms for the past 1 month.

On examination, uncorrected visual acuity was 20/20 (Snellen's visual acuity) in her right eye and perception of light was negative in her left eye. Dynamic retinoscopy revealed varying myopic reflex in her left eye and normal reflex in the right, however, cycloplegic retinoscopy was normal in both eyes. Anterior segment evaluation using slit-lamp biomicroscopy was normal, with brisk pupillary reactions and no relative afferent papillary defect in either eye. Posterior segment examination showed healthy disc, normal macula, and retinal periphery in both eyes. Menace reflex was intact. The results of malingering tests (repeated multiple times, by different examiners) such as fogging test and prism refixation test were negative.

Optic coherence tomography scan showed normal optic nerve anatomy and normal retinal thickness in both eyes. Visual evoked potential (VEP) revealed a significant decrease in amplitude in her left eye as compared to her right eye. Magnetic resonance imaging (MRI) of the brain and optic nerves was normal.

With unexplained vision loss in her left eye associated with an abnormal VEP, the patient was referred to a neurologist for further evaluation.

The patient was admitted and evaluated by a neurologist. Complete blood count, differential count, liver function test, urine analysis, cerebrospinal fluid analysis, electroencephalogram, and MRI brain were normal. During the course of admission in hospital, she reported that she regained vision suddenly. After extensive workup, resulting in findings being inconsistent with any organic neurological cause, the patient was transferred for psychiatric assessment. Following detailed evaluation, she was diagnosed to have psychogenic blindness/dissociative conversion disorder.

She was advised to consult a psychologist for counseling sessions. Although the parents were initially not convinced regarding the need for psychiatric consultation, they agreed to go ahead with it as there was no improvement in the child's condition.

Following 1 month of psychotherapy, her uncorrected visual acuity was 20/20 in her right eye and 20/30 in her left eye after fogging the right eye.


  Discussion Top


Conversion disorder is defined as a psychiatric illness in which symptoms and signs affecting voluntary motor or sensory function are unexplained by a neurological or general medical condition.[1] The word conversion refers to the substitution of a somatic symptom, such as blindness, paralysis, dystonia, psychogenic nonepileptic seizures, anesthesia, swallowing difficulties, motor tics, difficulty in walking, hallucinations, and dementia, for a repressed idea.[2],[3],[4]

Conversion symptoms in most cases begin with some stressor, trauma, or psychological distress that manifests as a physical deficit. There is no underlying physical cause for symptoms, and affected individual cannot control the symptoms.

Psychogenic blindness is a rare presentation commonly seen in younger age and in females.[5],[6] It should be suspected in patients with complaints of recent-onset defective vision, when no organic etiology can be diagnosed following exhaustive examination and investigation or when the ocular findings are inconsistent with degree of visual impairment. Other terminologies used are functional visual loss, psychogenic blindness, hysterical blindness, nonphysiological visual loss, or conversion syndrome.[7]

Nonorganic visual loss accounts for approximately 1% of blindness presenting to an ophthalmologist. The most common reporting complaint is reduction of visual acuity (36%–40%).[8] Two possible differentials for the same are psychogenic blindness and malingering. Psychogenic blindness occurs in various psychiatric conditions. Its pathogenesis is not well known. There are speculations that conversion reaction uses a physical symptom to express a psychological conflict.[6] However, in malingering, the patient claims visual loss for secondary gain.

Various tests which are recommended for evaluation of psychogenic blindness are fogging test, pupil splitting prism test, polaroid test, duochrome test, stereoscopic tests, VEP, and electroretinography.[5] Other clues which suggest possible malingering include smooth entrance into consultation room, an intact menace reflex, and failure to direct eyes toward own hands during tasks.

In our patient, findings were inconsistent with any organic cause. The possible explanation for decreased amplitude in VEP test could be the effect of defocus and distracted attention during recording. In addition, the patient had a history of panic attacks and hallucination episodes, which suggested need for psychiatric assessment.

Treatment consists of psychoeducation, reassurance, and regular follow-up. Parents should be reassured about excellent prognosis associated with nonorganic visual loss. Placebos such as eye drops, orthoptic exercises, or spectacles are better avoided as they could undermine the reassurance.[6]

Our patient, after prompt referral to a psychiatrist and following psychology intervention, showed improvement within a few weeks of therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ballmaier M, Schmidt R. Conversion disorder revisited. Funct Neurol 2005;20:105-13.  Back to cited text no. 1
    
2.
Blitzstein SM. Recognizing and treating conversion disorder. Virtual Mentor 2008;10:158-60.  Back to cited text no. 2
    
3.
Freud S. Freud S, Strachey J, Freud A. The neuro-psychoses of defense; Institute of Psychoanalysis (editors). In: The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth Press and the Institute of Psycho-Analysis; 1962. p. 45-61.  Back to cited text no. 3
    
4.
Marshall S, Bienenfeld D. Conversion disorder. Medscape. Drugs and Diseases; June, 26, 2013. Available from: http://emedicine.medscape.com/article/287464-overview. [Last accessed on 2015 May 30].  Back to cited text no. 4
    
5.
Beatty S. Non-organic visual loss. Postgrad Med J 1999;75:201-7.  Back to cited text no. 5
    
6.
Kathol RG, Cox TA, Corbett JJ, Thompson HS, Clancy J. Functional visual loss: I. A true psychiatric disorder? Psychol Med 1983;13:307-14.  Back to cited text no. 6
    
7.
Bruce BB, Newman NJ. Functional visual loss. Neurol Clin 2010;28:789-802.  Back to cited text no. 7
    
8.
Dutta A, Poudel R, Thapa LJ, Pokhrel B. Psychogenic blindness: A rare presentation. J Psychiatrists Assoc Nepal 2013;2:49-51.  Back to cited text no. 8
    




 

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