Both eyes vision is blurred or just the problem is with one eye ? What is the ocular history based on parents answers ( any trauma, etc). Do you mean checking VA through mirror and dublicating the distance to 6 m ? What is VA in each eye ? Do four dot test.

History is negative. She refers that vision is blurred in both eyes and that she can't see the letters.

How is she doing at school/kindergarden? Any recent stressful events? Any findings from complete examination of the eyes incl peripheral retina?

She's doing well. My question was how to procede after the first step, fundus examination under cycloplegia is usually my last step in a visit, even if in doubtful cases I give a look at the posterior pole without pupil dilatation. Well in such a case the real differential diagnosis is malingering. So my question was about which should be the next step with a child, supposing the reasons for whose he/she "doesn't want to see" :-) I've listed a few in my mind and tried with one. The first I thought worked very well. Could you imagine which one?

I would suggest to refer this girl to a pediatric ophthalmologist or optometrist as soon as possible.

Take her to an Optometrist to get her eyes examined

No my question is not related to this topic. It's supposed that the examiner is a skilled pediatric ophthalmologist, and further I said that there is a suspect of malingering. If I refer the girl to an optometrist what does this will change? I asked what you practically do, a trick to unmask the atypical behaviour.....I managed this case with an easy trick. I said the girl " Now I will let you try a magical frame which will let you see suddenly " I mounted a +0.12 sph. on both sides of the trial frame and.......as if by magic the child said " Ooohhh! Now I see " That's all. The difficulty then has been to explain the problem to the parents :-)

Good idea with the "magic frame" tip! And the mirror, dr Shahsuvaryan. In my last case with this problem I also put on a +0,12D lens and strongly suggested that vision would be completely restored, and the young patient went from "no vision" to LogMar 0,0 (or snellen 1,0). The power of suggestion. I often refer these patients to the GP with a note on possible psychosocial problems (actually I keep in mind a youngster/child trying to communicate abuse). Good topic here! Other good ideas?

The magic frame is a good idea for functional amblyopia in a young child. It is important to examine the eyes fully. Especially if this technique does not work. In other words the eye should be fully examined to exclude an organic aetiology of the reduced vision. Sometimes suddenly discovered reduced acuity can be but a recent observation of a long present problem- so refractive abnormalities, abnormalities of lens, retina and optic nerve must be excluded.

If all else fails then visual electrophysiology can objectively exclude retinal or optic nerve dysfunction. The VEP can display optic nerve dysfunction and indeed refined techniques can be used to objectively measure visual acuity.

Only when all examinations and tests are found to be normal can the diagnosis of Functional amblyopia be made.

This child needs a comprehensive eye exam, with dilated fundus evaluation and cycloplegic retinoscopy and refraction. As part of this, she monocular and binocular acuity testing in the distance and at near.

I think a child with a suddenly loss of vision, as the one you reported, shouldbe having trouble with cotidianity, I suggest to observe very carefully her behaviour, also try some other types of visual test like a Preferential Looking test, although they are not very appropiate for her age, as they are so different to Lea or Snellen charts that it is harder to simulate or be consistent with a vision loss not related to defocus.

In your case I would be very concerned about possible ocular arterial problems.

First you did not identify whether it was a monocular or a binocular blurring for the complete visual field - i.e. blurring of the binocular field as well as both monocular crescents, without any sparing of the monocular crescents.

Second I strongly urge you to have the child examine by a good ophthalmologist ASAP. If it is a vascular problem, time is of the essence.

my best wishes

I. Steele-Russell, PhD

Professor in Visual Science and Neuroanatomy

1)check fields of vision using simple confrontation facing patient and using your hands as a target, typically in a situation like this, fields will be less than your shoulder width

2) stand 3m from patient, get Px to concentrate on your nose, ask them to identify (without moving their eyes) how far down your body they can "see" at the same time as concentrating on your nose. You can compare their field to yours

3) using a "near vision" chart, check the near and far ranges of clear vision, (normal range 8-80 cm - but with these children more often very limited ie 20-25cm

4) as you have already identified, low plus ( +0..50) and small prisms 1in e/e or 2 down e/e can expand these fields and ranges and improve convergence

You can see the change in convergence stress with these lenses on a video on https://www.facebook.com/photo.php?v=385199718288199&set=vb.371502832991221&type=2&theater

Feel free to get back to me

Geoff Shayler (Optometrist)

Eyes grow from birth to ~13 years of age. From birth to five years of age the diameter increases by about 6mm. The rapid development of the structures included in the eyeball may entail certain developmental abnormalities, leading e.g. to the formation of various forms of aberration, such as astigmatism, coma, or trefoil. Aberrations tend to cause acuity deterioration, seeing color fringing around the perceived objects, and image distortion. I recommend to do one of wavefront eye exam, to exclude aberrations, and at the same time check condition of her lacrimal glands, cornea, iris acomodation to light, condition of lens, and intraocular pressure. If these tests will show nothing, than do a computer tomography of occipital regions of the brain.

I agree with the comprehensive examination and would certainly do a cycloplegic refraction and dilated fundus examination. However before embarking on this road an easy way to find out if she has a refractive problems would be to use a pinhole test, if the acuity improves then the cause is most likely uncorrected refractive error. Failing any improvement things are a bit more ominous and she should then have a comprehensive workup including neurological testing if the eye exam fails to show any problems. The low plus lens is a good trick but it does not always work well, some of these youngsters are cleverer than we think!

Whereas I agree that unexplained visual loss needs to be comprehensively assessed (Refractive, Ocular Pathology or Neurological)  until one can identify a probable cause and thereafter initiate any treatment deemed appropriate, in the early phase the trick is to see if visual behaviour, in a normal environment preferably while the child is unaware of being watched, correlates with the visual function (VA,VFs,CS etc) results being recorded. If a 6 year old is faking it there is often something deep down in their life that is precipitating this type of behaviour.

JJ

What was the followup of this girl..I wonder why no one asked for MRI brain and CSF analysis for OCB ..Even serum Aquaporin 4..

I know time since the onnset has passed..but if you kindly hint fot diagnosis and follow up..I ll be appreciated. 

Take the child to get their eyes examined by an optometrist.

craig

As with anyone who has an acute or chronic complaint of reduced vision, a comprehensive eye exam is the only way to sort out if there truly is a problem.   Doing screening tests such as looking through a pinhole does not answer the question, is there a bigger underlying problem that caused this change in vision.  This child needs a refractive analysis and a dilated eye exam by an eye care professional.     

Comprehensive visual exam, as soon as possible

Optic neuritis is the ffirst possible  diagnosis ..either retrobulbar  with normal fundus or genuine optic neuriitis.

Use the Cortical Visual impairment interventions to regain any lost visual skills if necessary.  But definitely assess for this.  I agree that optic neuritis or optical migraines and other similar causes are the most probable.   

Have to consider non-organic causes.   Presumably had normal vision before this all started.   Needs comprehensive eye exam first.

Hi Dr. Wilkinson

I used to work for IBSSS once.  Met you at several Low Vision Clinic during the time I was serving northwest quadrant.   Good to see you are still in the field.

Listen to his suggestion Dr. Maimone, Dr. Wilkinson has been in the field of visual impairment and blindness many years and many different opportunities to learn from the patients.

Dr. Kenalea Johnson, COMS

Hi Dr. Johnson

Good to hear from you.   Glad to know you are still in the field as well.

Regards,

Mark

75 and still working.  Now finding lots of great experience with elderly developmentally delayed in supported living.  Any information for me about how to determine if it is sundowners vs non-24 when there is no expressive communication?

Also, doing research listed here.  Waiting for connection to human subjects board to begin.

Kenalea

Sorry, cannot help on the sundowners versus non-24 folks.

urgent comprehensive eye examination and previous records of the same can through some light into it.

Comprehensive examination as soon as possible.

What about toxoplasmosis? other than that I also agree with a workup for optic neuritis or possible cortical involvement.

Toxo would not cause bilateral loss in a short time like this presentation.   Additionally, CVI would not spontaneously happen without some precipitating event.  A comprehensive exam is always indicated first when there is vision loss.   This would allow for an assessment of non-organic vision loss as well.  

I agree an expert medical examination is an immediate step.  My questions of the clinician you visit are:  Is she also complaining of fatigue, with enhanced darkened circles under her eyes?  ...and what about pupillary response?  Is there an afferent pupil?  Children are prone to nasal- and ethmoid-sinus infections. These can transition to an orbital infection, if one or both sinuses have a break in their portion of orbital wall.

Exactly, this was the first consideration I made before proceeding because testing and retesting children may become demanding. In this case I told the child the history of a magician that was able to let her see clearly with a magic lens. Suddenly she saw 20/20 with a +0.12 lens while uncorrected she said that she wasn't able to see nothing on the chart.

I had a similar case. A 5 year old girl with a very low vision in the left eye with no signs of compromise. After performing visual evoked potentials and electroretinogram (with simple skin electrodes and steady-state strategy, 10 minutes) I was sure that there was no diseases. So I said in front of her family that I found a magical lens ... + 0.12 of course. Electrophysiology of vision is my secret weapon!

Flash ERG (for testing cone, rod, bipolar cells, respectively), multifocal ERG (for testing retinal function at different parts of retina), visual evoked potential (for testing the function from retina to visual cortex) and OCT (for testing the thickness of retinal layers) can be performed. Visual field test can also be performed if the patient can cooperate.

it seems malingering, just tell her relatives there's nothing wrong with her eyes

before doing that, just be sure at 100% (pupils examination, cycloplegia and careful retina and VF examination)

Dear collegues,

I find the Mojon Chart very useful for the detection of "nonorganic" visual loss, here the link: Article A new optotype chart for detection of nonorganic visual loss

Of course, it has to be made sure by thorough ophthalmological exam that the visual loss is indeed "nonorganic".

Then I talk to the parents alone, explaining that the eyes are all right, but that the prescription of "fake" glasses is a good solution. Meanwhile, the patient is busied with e.g. colour testing or taking a look at the Titmus fly in another room.

Then, as a therapy, I prescribe plano or + 0.25 glasses, reassuring him or her in an earnest fashion that the glasses will lead to normal vision in a short time. Thus, the patient is shown an "easy way out" without losing face, and everybody is happy.

Up to now, this procedure has always worked.

Thanks to Mr. Maimone for the great "magician idea", which I am looking forward to apply in the next case to come.