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Abstract Background/aims Functional visual symptoms are relatively common symptoms seen by ophthalmologists. However, there are no consensus guidelines on ophthalmological management of this condition, and there is a paucity of knowledge about the collective challenges experienced in treating patients with functional visual symptoms. In order to establish an ophthalmological perspective on this condition, we undertook the first national survey of experience, knowledge and management of functional visual symptoms amongst ophthalmologists.MethodsAn online survey was disseminated to ophthalmologists in the UK via all Royal College of Ophthalmology college tutors.ResultsOne hundred nineteen ophthalmologists completed the survey. Functional visual symptoms accounted for 3% of all new referrals. Forty per cent of respondents felt they had a good understanding of functional visual symptoms. Two-thirds reported a need for further training in this area. Respondents estimated two-thirds of patients’ symptoms improved, but a third experienced severe or extreme disability. Following diagnosis, a minority of patients were referred to mental health or neurology services. The majority of respondents described difficulty discussing psychological factors, with a lack of time or space in a clinic preventing a holistic approach. Free text comments highlighted a lack of access to dedicated psychological support for patients.ConclusionFunctional visual symptoms are disabling and are seen relatively frequently by ophthalmologists. This preliminary survey suggests that care pathways for patients with functional visual symptoms could be optimised. Fostering links between ophthalmology and existing services with expertise in functional disorders could improve patient care and clinician education and ultimately encourage research in this area.

Background/Objectives: Tangent screen perimetry is a valuable tool for detecting functional visual loss (FVL), which is suspected when the visual field fails to expand as expected with distance. However, there is currently a lack of research documenting the specific tangent screen patterns produced by patients with organic visual loss (OVL), defined as visual field loss caused by identifiable structural or neurologic pathology. This study aims to characterize the visual field patterns observed in patients with organic and functional pathologies during tangent screen perimetry and evaluate its diagnostic efficacy in confirming FVL. Methods: Medical records of patients from Seoul National University Bundang Hospital between August 2009 and August 2019 were reviewed. All subjects underwent a comprehensive neuro-ophthalmologic examination with additional testing to confirm the diagnosis of OVL or FVL. A total of 126 eyes from 76 patients exhibiting visual field constriction within 30 degrees were included. The tangent ratio (TR) was defined as the average visual field (in radians) at a far distance (e.g., 2 m) divided by the average visual field at a near distance (e.g., 1 m). The visual field patterns and TR were analyzed, and the diagnostic value of TR in detecting FVL was determined. Results: The clover leaf pattern and reversal pattern were observed in 8.8% and 12.7% of FVL cases, respectively, whereas no such patterns were found in OVL cases (p = 0.002, p < 0.001). The TR varied from 0.50 to 1.06 (mean 0.77 ± 0.16) in OVL and from 0.33 to 1.03 (mean 0.65 ± 0.15) in FVL (p < 0.001). Younger age, a clover leaf pattern or reversal pattern on tangent screen perimetry, and a lower TR were significantly associated with FVL. Conclusions: Tangent screen perimetry is an effective adjunct for differentiating functional from organic visual field loss, particularly in cases of visual field constriction.

Background: Functional visual loss (FVL), also known as Non-Organic Visual Loss (NOVL), is a condition characterized by visual impairment without an identifiable organic cause. FVL has been associated with psychological distress and psychiatric disorders, factors that were significantly impacted by the COVID-19 pandemic. This study aimed to assess the incidence of FVL before and after the COVID-19 pandemic and to explore potential underlying psychosocial factors contributing to its increase. Methods: We conducted a retrospective observational study at the University Eye Clinic, Milan, analyzing patient records from two six-month periods: pre-pandemic (January–June 2019) and post-pandemic (January–June 2023). We included patients aged 3–80 years old and collected their demographic, clinical, and ophthalmological data. Statistical analyses compared the FVL incidence rates and symptom prevalence across both periods. Results: The incidence of FVL significantly increased from 4.0% pre-pandemic to 9.1% post-pandemic (p < 0.001). Certain symptoms, such as eye irritation and luminous scotoma, showed significant changes post-pandemic. Pediatric patients demonstrated an increased tendency towards emulation behavior. Conclusions: The COVID-19 pandemic appears to have influenced the prevalence and characteristics of FVL, likely due to heightened psychological distress. Further research is needed to explore the long-term trends and intervention strategies.

BackgroundAcute bilateral painless visual loss is an uncommon presentation and poses a significant diagnostic challenge. Without overt neurological deficits or significant vascular risk factors, stroke may not be the initial consideration. However, infarctions in the occipitoparietal regions can result in profound visual impairment, despite normal early CT head findings.Case presentationWe present the case of a 59-year-old male with no known comorbidities who developed acute bilateral painless visual loss, reducing his vision to hand motion in one eye and finger counting at 30 cm in the other. His neurological and ophthalmological examinations were otherwise unremarkable, and initial CT head and cerebral CT angiography were normal. Due to the absence of vascular risk factors and normal early neuroimaging, bilateral retrobulbar neuritis was suspected. However, a delayed MRI obtained the next day revealed bilateral occipitoparietal ischemic infarctions. The patient was treated with dual antiplatelet therapy and statins. He showed slight improvement in visual acuity, although significant deficits remained.ConclusionThis case highlights the importance of considering posterior circulation strokes in patients with acute bilateral painless visual loss, even in the absence of traditional stroke risk factors. It emphasizes the role of advanced neuroimaging, particularly MRI, in diagnosing cortical strokes when initial CT head is unremarkable.

This is a pilot study to assess the clinical safety and efficacy of recording real-time flash visual evoked potentials (VEPs) using the SightSaver TM Visual Stimulator mask during prone spine surgery. A prospective, observational pilot study. Twenty patients presenting for spine surgery (microdiscectomy, 1–2 level lumbar fusion, or > 2 levels thoraco-lumbar fusion) were enrolled. The SightSaver™ Visual Stimulator™ was used to elicit VEPs throughout surgery. Somatosensory evoked potentials (SSEPs) were simultaneously recorded. All patients underwent general anesthesia with a combination of intravenous and inhaled agents. The presence, absence, and changes in VEP were qualitatively analyzed. Reproducible VEPs were elicited in 18/20 patients (36/40 eyes). VEPs were exquisitely sensitive to changes in anesthesia and decayed with rising MAC of isoflurane and/or N2O. Decrements in VEPs were observed without concomitant changes in SSEPs. The mask was simple to apply and use and was not associated with adverse effects. The SightSaver™ mask represents an emerging technology for monitoring developing visual insults during surgery. The definitive applications remain to be determined, but likely include use in select patients and/or surgeries. Here, we have validated the device as safe and effective, and show that VEPs can be recorded in real time under general anesthesia in the prone position. Future studies should be directed towards understanding the ideal anesthetic regimen to facilitate stable VEP recording during prone spine surgery.

To identify new types of clinical findings that could be used to diagnose and treat non-organic visual loss (NOVL). This study retrospectively examined the records of 191 patients diagnosed with NOVL at the Kato Eye Clinic. Clinical characteristics, including uncorrected visual acuity (UCVA) and complaints of vision loss, were compared in 125 of 191 patients with NOVL and control subjects with organic refractive errors, identified during annual school health checks. If available, familial background data for the NOVL patients were compared with data from a mass population study. Familial background data included the presence of siblings, and whether the mother worked outside the home. Patients with NOVL were more likely to be younger and female ( =0.02, and <0.001, respectively). UCVA was statistically similar in the better eyes of the NOVL and control subjects ( =0.60), even though the NOVL patients were much more likely to be emmetropic ( <0.001). Complaints of vision loss were significantly more common in the patients with NOVL than in the control subjects ( =0.001). There was no significant difference in the presence of siblings between the subjects in the mass population study and the patients with NOVL ( =0.38), but the NOVL patients were significantly more likely to have a mother who did not work outside the home ( =0.01). Patients with NOVL tended to be younger, female and to complain more often of vision loss, compared to control subjects with organic refractive errors. Familial background factors, including the presence of siblings or a mother working outside the home, seemed not to be associated with the pathogenesis of NOVL, compared to subjects in a mass population study.

Disorders that specifically affect central and peripheral vision constitute invaluable models to study how the human brain adapts to visual deafferentation. We explored cortical changes after the loss of central or peripheral vision. Cortical thickness (CoTks) and resting-state cortical entropy (rs-CoEn), as a surrogate for neural and synaptic complexity, were extracted in 12 Stargardt macular dystrophy, 12 retinitis pigmentosa (tunnel vision stage), and 14 normally sighted subjects. When compared to controls, both groups with visual loss exhibited decreased CoTks in dorsal area V3d. Peripheral visual field loss also showed a specific CoTks decrease in early visual cortex and ventral area V4, while central visual field loss in dorsal area V3A. Only central visual field loss exhibited increased CoEn in LO-2 area and FG1. Current results revealed biomarkers of brain plasticity within the dorsal and the ventral visual streams following central and peripheral visual field defects.

We present the results from a patient with relapsing optic neuropathy treated within the Stem Cell Ophthalmology Treatment Study (SCOTS). SCOTS is an Institutional Review Board approved clinical trial and has become the largest ophthalmology stem cell study registered at the National Institutes of Health to date (www.clinicaltrials.gov Identifier NCT 01920867). SCOTS utilizes autologous bone marrow-derived stem cells (BMSCs) for treatment of retinal and optic nerve diseases. Pre-treatment and post-treatment comprehensive eye exams of a 54 year old female patient were performed both at the Florida Study Center, USA and at The Eye Center of Columbus, USA. As a consequence of a relapsing optic neuritis, the patient's previously normal visual acuity decreased to between 20/350 and 20/400 in the right eye and to 20/70 in the left eye. Significant visual field loss developed bilaterally. The patient underwent a right eye vitrectomy with injection of BMSCs into the optic nerve of the right eyeand retrobulbar, subtenon and intravitreal injection of BMSCs in the left eye. At 15 months after SCOTS treatment, the patient's visual acuity had improved to 20/150 in the right eye and 20/20 in the left eye. Bilateral visual fields improved markedly. Both macular thickness and fast retinal nerve fiber layer thickness were maximally improved at 3 and 6 months after SCOTS treatment. The patient also reduced her mycophenylate dose from 1,500 mg per day to 500 mg per day and required no steroid pulse therapy during the 15-month follow up.

To report non-organic visual loss (NOVL) following cataract surgery with multifocal intraocular lens (IOL) implantation. After reviewing consecutive cases of NOVL diagnosed by a single neuro-ophthalmologist over a one year period, two patients reported herein attributed their visual symptoms to cataract surgery and multifocal IOL implantation. In both patients variability was noted in visual function and kinetic perimetry demonstrated non-organic visual field loss. Initially, refractive surgeons considered lens exchange, which was avoided after neuro-ophthalmic evaluation in both cases. This report should alert cataract and refractive surgeons to the possibility of NOVL as an explanation for dissatisfaction after cataract surgery with multifocal IOL implantation.

Post-operative visual loss (POVL) is a rare, albeit potentially serious complication of general anaesthesia. This report describes the case of a 54-year-old woman who developed transient POVL after general anaesthesia following a left posterior parietal meningioma surgery in the prone position and discusses the usefulness of visual evoked potentials monitoring in such situations.