Healthcare Utilization and Characteristics of Patients With Functional Visual Loss
abstract
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Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
Functional visual loss (FVL) is characterized by complaints of visual impairment without evidence of an organic cause. Physicians are often reluctant to diagnose FVL, thus little is known about the healthcare utilization in patients with FVL.
DESIGN
Retrospective case series METHODS: 110 patients that were seen at two university-affiliated neuro-ophthalmology practices who were diagnosed with FVL were included. Medical records were evaluated, and data were collected on demographics, clinical presentation, ophthalmologic examination, neuroimaging, ancillary tests, and other healthcare provider visits and treatments.
RESULTS
Over 70% of patients with FVL were women with a mean age of 37 ± 15 years. The presenting complaint in 71.8% (79/110) of participants was decreased vision which was bilateral in over 50% of cases. Close to half (53/110) endorsed at least one co-existing psychiatric or neurologic diagnosis. The mean number of different medical specialists seen before neuro-ophthalmic consultation was 3.7 ± 2.6, and the average number of healthcare visits was 4.6 ± 4.4. Each patient had 2.2 ± 1.8 neuroimaging studies performed. Fifteen percent of patients underwent unnecessary treatments, including receiving steroids, visual therapy, and prisms.
CONCLUSIONS
Patients with FVL typically see at least three different healthcare providers across four different visits and undergo at least 2 neuro-imaging studies before having neuro-ophthalmic consultation. To avoid this undue burden on patients and the healthcare system, clinicians should refer patients with suspected FVL to a neuro-ophthalmologist to confirm the diagnosis of FVL and appropriately counsel the patient.
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Additional Info
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Characteristics of 110 patients with functional visual loss
Am J Ophthalmol 2023 Feb 09;[EPub Ahead of Print], I Sverdlichenko, N Brossard-Barbosa, JA Micieli, E MargolinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
In this paper, the authors discussed the clinical findings in 110 patients with functional vision loss. They found that 70% of the patients "presented with decreased vision as the chief complaint, followed by visual field defect, transient vision loss/blur, or diplopia." The authors highlighted the costs in terms of time and expense to the patient and the healthcare system resulting from the lack of a definitive diagnosis for many of these patients as they were evaluated by multiple providers. Perhaps the authors should have placed a greater emphasis on the fact that functional vision loss is a positive diagnosis and not one of exclusion. Moreover, there is no guarantee that an individual with psychological problems will not have a coexisting or even an underlying nonfunctional condition. Therefore, it would seem doubly important that patients be examined by a neuro-ophthalmologist to establish a definitive diagnosis of functional vision loss and rule out any comorbid nonfunctional conditions.
Functional visual loss (FVL) is a diagnosis of exclusion that all practitioners should be able to handle better. In fact, precisely because it is so fundamental, I disagree with the authors' premise that all patients with suspected FVL should be referred to neuro-ophthalmologists in a more timely manner. Their contention is that these patients are subjected to unnecessary and expensive differential diagnostic tests, such as imaging studies, which seems to be the crux of the issue rather than the need to refer. A total of 48% of the patients involved in this study had comorbid psychiatric disorders, which is a clue that FVL is the diagnosis. Moreover, 96% of the patients experienced an improvement in visual acuity when reverse fogging was conducted, which is another clue to the diagnosis. Therefore, one could make a counter-argument that, in most cases, referral to a neuro-ophthalmologist is overkill and is usually performed for medicolegal reasons or because of chair cost time. One could argue that improved awareness of differential diagnostic testing, rather than increasing referrals, seems to be the appropriate approach in this situation.