Functional vision loss in children: What to say to parents, the patient

Take-home message: Functional vision loss in children is a relatively common problem. Although physicians may be hesitant to delve into conversations with children and parents when there is no evidence of organic disease, it is better to probe for cause of stress, anxiety, or depression stemming from issues with family, school, outside activities, or friends, and to identify for the patient and parents areas for attention that may be previously unknown or overlooked.

By Nancy Groves; Reviewed by R. Michael Siatkowski, MD

Oklahoma City - Sooner or later a child will show up in your office, accompanied by worried parents, complaining of vision loss. Your examination shows no signs of organic disease, and whether through stereo acuity testing, fogging, or some other technique, you have proven that visual function is normal. What do you say next, to the child and to the adults?

This is not the time to forcefully confront either the patient or the parents with accusations of malingering or lying but rather to be reassuring as you present the facts, said R. Michael Siatkowski, MD , David W. Parke II, MD, professor , vice chairman for academic affairs, and residency program director, Dean McGee Eye Institute, University of Oklahoma, Oklahoma City.

Explain that the results of the eye exam were normal and that results of your tests actually demonstrated visual function much better than initially reported. From there, you can begin to work with the patient and parents to determine the cause of the functional vision loss.

“This is not an uncommon problem in kids,” Dr. Siatkowski said. “The prototypical patient is a girl between 8 and 13, but all ages and both sexes are affected.

“This is something that every ophthalmologist is going to encounter . ” he added. “It’ s easy to develop an approach and a routine to use with these patients. We do our patients a great service by fixing their vision with medicine or surgery, but we do just as great or even greater a service by helping the entire dynamics of a child ’ s or a family ’ s life to improve. ”

Dr. Siatkowski also urged physicians to pursue rather than avoid these potentially sensitive conversations.

Some physicians may fear that closely examining the causes of functional vision loss could be too emotional, confrontational, or unproductive, but if the issue is approached honestly and openly, families are usually accepting, and parents especially are relieved to learn that nothing is physically wrong.

Social, psychological factors

In children, the trigger in nearly half of the cases of functional vision loss is social, psychological, or family-related. A child may be bullied at school or stressed from academic demands or a schedule overloaded with extracurricular activities. Life at home may have been disrupted by a move, a new sibling, divorce, or a death in the family, or perhaps friendships are unraveling. The conversation with the child and parents usually uncovers the issues behind the medical complaint.

Dr. Siatkowski follows the diagnosis by introducing the concept of SADness, which stands for stress, anxiety, and depression.

“The way I explain it is that we all have SADness in our lives, and if we don’t find an outlet for it, it has to come out in some way. For some people the SADness comes out as headaches, stomachaches, or nausea, while other people may experience muscle twitches. But for some patients, the way this comes out is in their vision.”

Next, the goal is to identify and decrease the sources of the SADness.

“Sometimes we can make significant changes in this regard but sometimes we can’t,” Dr. Siatkowski said. “Other times we may suggest a different outlet for them.”

Depending on the situation, he may recommend measures such as physical exercise or activity, getting more sleep, decompressing an extracurricular schedule, or psychological counseling.

“Sometimes just knowing the fact that vision loss is a symptom of SADness is enough to mitigate the symptoms a lot because they don’t have to worry that something is actually physically wrong,” he explained.

The next phase of management is to allow time for the patient and family to deal with the problem areas and learn new outlets for coping with SADness.

However, if it has not been proven in the office that visual function is completely normal, or if the patient or family is unable to fully accept the concept of functional vision loss, Dr. Siatkowski strongly advises a follow-up appointment to make sure no organic disease has been overlooked.

Typically the patient will have progressed by the second appointment and no further attention is needed. In his practice, Dr. Siatkowski refers only about 10% of the children with functional vision loss to a psychiatrist or psychologist.

He also noted that in a fraction of cases, about 1% to 2%, functional vision loss arises from emotional, physical, or sexual abuse.

“If there’s any suspicion in that regard, you try to separate the kids and the parents and talk to them privately in the presence of a witness, and you may have to call a social worker or someone else who should be involved,” he said.

One red flag is a family in which the adults in particular seem overly eager to emphasize that everything is perfect in all aspects of their lives. Adults who do not want to talk, seem detached and unemotional, or are confrontational also should arouse suspicion.

Two other things to watch for include the malingering patient, someone who purposefully claims vision loss for secondary gain. This is less common in children than adults, Dr. Siatkowski said, and when children act this way it ’s typically to avoid a particular activity or person rather than for monetary gain.

Functional overlay

The other entity is functional overlay, which is a functional visual loss superimposed on organic disease.

For example, a child with Stargardt disease may report 20/400 vision when the true acuity may be 20/50, and the difference is functional overlay. In functional overlay, the common triggers may be present, but in addition the patient and family may be afraid that the disease will lead to blindness.

In these cases reassurance that complete blindness will not occur may be sufficient to improve the functional component, and if not, use of any of the measures described above as appropriate, Dr. Siatkowski said.

R. Michael Siatkowski, MD

E: rmichael-siatkowski@dmei.org

Dr. Siatkowski did not report any relevant financial relationships.