Documenta Ophthalmologica 82: 369-382, 1992. 9 1992 Kluwer Academic Publishers. Printed in the Netherlands.

Visual impairment in hysteria M I C H A E L C. BARRIS 1, DAVID I. K A U F M A N 1 & DOMINIC BARBERIO 2 Departments of llnternal Medicine (Division of Visual Science) and 2psychiatry, Michigan State University, East Lansing, USA Accepted 24 November 1992

Key words: Flash electroretinography, Goldmann perimetry, Hysteria, Magnetic resonance images, Pattern visual evoked potentials, Snellen visual acuity Abstract. We have reviewed the charts of 45 neuro-ophthamological patients diagnosed with 79 monocular visual field or visual acuity losses secondary to non-organic etiology. Our aim was to determine the percentage of patients that have improvement in vision. As part of the protocol, all patients had magnetic resonance images, pattern visual evoked potentials, and flash electroretinography in addition to complete neuro-ophthalmological examinations. A single physician performed both the initial and follow-up examinations of all patients. Thirty-three percent of these patients had visual field defects only, 62% had both visual field defects and visual acuity defects, and 5% had only visual acuity defects. After organic disease was ruled out, all were given a timetable for recovery and clear reassurance regarding their prognoses for visual recovery. Seventy-eight percent of these patients showed improvement or were normal, while 22% showed no improvement. Younger patients without obvious psychiatric disorder had better prognoses than older patients.

Introduction Miller [1] has summarized the literature on theoretical approaches to hysteria. He has noted the lack of consensus on the etiology of hysteria and even on its existence. Weller & Wiedemann [2] have reviewed specifically ophthalmological aspects of hysteria. Merskey [3] stresses the importance of hysteria, as the foundation of psychoanalytic theory and of the understanding of the mind. He discusses hysteria as an issue in difficult diagnostic cases and finds some evidence for occult organic disease in cases historically diagnosed as hysterical. He notes that 'a lack of adequate technology and a proper unwillingness to undertake hazardous investigations for obscure symptoms may encourage a false attribution of psychological symptoms to a physical illness'. Furthermore, he reviews the social consequences of hysteria. Finally, he emphasizes that the 'physician should be as committed to understanding and treating patients with hysteria as those with any other psychological or physical disorder.' A spiral or helical visual field usually indicates hysterical visual loss. However, it is also well known that patients with retinitis pigmentosa,

370 glaucoma, bilateral optic nerve lesions, chiasm lesions, bilateral visual radiation lesions, fatigue, poor understanding of the test, and malingering may have restricted visual fields [4, 5]. The aim of this study was to review a population of patients seen in follow-up examinations who had been carefully documented to be free of organic pathology in order to quantify changes in visual fields and visual acuities. We have presented portions of this work at the 1992 annual meeting of the Association for Research in Vision and Ophthalmology in Sarasota, Florida, USA [6].

Subjects and methods

Subjects' We reviewed the charts of 72 patients with reduced visual acuities and/or restricted or helical visual field disorders. These patients were seen between 1984 and 1990 at the Neuro-Visual Unit at Michigan State University. Twenty-seven of 72 patients did not return for complete follow-up examinations. The charts of the remaining 45 patients seen longitudinally are analyzed here. The neuro-ophthalmological examination included a careful neuro-ophthalmological history, Goldmann perimetry performed in accordance with the procedure described by Anderson [7], visual acuity determination, color vision assessment with Ishihara plates, fundoscopy, biomicroscopy, and ocular motility and pupil evaluation. As a matter of routine examination of these patients, hematologic and chemistry evaluations, pattern visual evoked potentials, flash electroretinograms, and magnetic resonance imaging o f the brain were done to carefully eliminate occult pathology, as discussed by Merskey [3]. All patients showed visual acuity impairment, visual field impairment, or both. No magnetic resonance image, pattern visual evoked potential, or flash electroretinogram was read as abnormal in these patients. No patient had any ophthalmologic or neurologic findings consistent with organic disease.

Methods Hysterical visual loss was documented by typical response to visual field examination and performance on visual acuity testing. Goldmann perimetry was performed first with a I4e stimulus. If the [4e isopter was highly restricted, helical, or absent, we next used a V4e stimulus. These V4e stimuli are noted with asterisks in Table 1 when data were reported using them. In each case, we took the value of the greatest Goldmann radius as the estimate of potential visual field area, which we calculated as pi times

371 the radius (in degrees) squared to arrive at an area in square degrees. In Table 1, this is reported as VF1 for the initial examination and VF2 for the follow-up. Change is reported as the difference between VF1 and VF2. A positive value represents improvement, a nil value represents no change, and a negative value indicates regression. Visual acuities were assessed with Snellen characters projected 4 meters from the patient. We took the patient's best performance with a pinhole and careful urging as the criterion acuity for the initial and follow-up examinations, reported respectively as VA1 and VA2 in Table 1. All patients whose examinations and work-ups were consistent with hysterical visual loss were given a timetable for recovery. The prescription of a timetable for recovery involved repeatedly reassuring the patients that no organic pathology has been uncovered. They were told that 'the brain is fine, and the eye is fine. There may be a problem with the brain playing tricks on the eye'. They were then instructed to view the center of a newspaper headline while concentrating on expanding the field of vision to include more and more letters on either side of the central character fixated. The patient was advised to repeat this procedure monocularly and twice daily before the follow-up examination. Another prescription was given in the case of decreased visual acuities. This prescription involved instructing the patients to look at large headlines while training themselves to see smaller and smaller print over a period of time. They were also told such training strategies should improve their vision over three to six weeks. In 1946, Yasuna [8] was the first to present the rationale for this management tactic.

Results

Table 1 presents the initial and follow-up visual acuities (VA1 and u and potential Goldmann visual field areas in square degrees (VF1 and VF2). The change between initial and follow-up visual field areas and comments are indicated for symmetrical visual fields. Figure 1 is the frequency histogram for 9 male patients by age in one-year intervals, while Fig. 2 is the frequency histogram for 36 female patients by age in one-year intervals. The distribution is skewed towards young ages in both groups. Table 2 summarizes the major findings of the review of patient charts. Seventy-eight percent of 45 patients who returned for follow-up examination showed improvement, while 22% showed no improvement. Seventy-four percent of 79 monocular visual field or visual acuity impairments in these 45 patients showed improvement. Furthermore, 82% (14/17) of monocular impairments in 9 male patients and 74% (46/62) of monocular impairments in 36 female patients showed improvement. Table 2 further analyzes these data by age greater or younger than 16 years and each gender. Patients

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Visual impairment in hysteria.

We have reviewed the charts of 45 neuro-ophthamological patients diagnosed with 79 monocular visual field or visual acuity losses secondary to non-org...
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