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Functional visual loss: A diagnosis of exclusion
LETTERS
Functional visual loss: A diagnosis of exclusion I read with interest the recent article by Villegas RB and Ilsen PF, “Functional visual loss: A diagnosis of exclusion” (Optometry 2007;78:523-533). The authors have done an excellent job outlining and describing the wide variety and clinical presentation of patients with functional visual loss. I would, however, challenge the conclusion and title of the paper which indicates that functional visual loss is a diagnosis of exclusion. In fact, traditional teaching has held that functional visual loss is a positive diagnosis made by demonstrating physiologic impossibilities. There is no doubt that the prudent practitioner will want to rule out organic disease in many cases of suspected functional visual loss especially when clinical testing is confusing or inconclusive. It is also known that many patients will experience “functional overlay” of true organic
disease further confounding an accurate diagnosis. It would be inappropriate, however, in all cases of functional visual loss to subject patients to an exhaustive battery of expensive and potentially risky testing when the diagnosis is positively established by demonstrating physiologic visual impossibilities. In these cases, reassurance, psychiatric evaluation, and careful follow-up would be the most appropriate management. Christopher J. Quinn, O.D. Omni Eye Services Iselin, New Jersey
Authors’ reply While functional vision loss can certainly be suspected on routine exam based on the patient’s response to vi-
sual and ophthalmologic testing, it is still a diagnosis of exclusion. However, we are not advocating that every suspected patient undergo the full battery of ancillary tests, as certain tests and procedures may be tedious, inconvenient, and excessive (particularly radiological imaging and electrophysiological tests). Since functional vision loss encompasses a wide variety of conditions, diagnosing cases of the condition should be varied accordingly. Depending on the particular circumstances with the patient, it is up to the individual practitioner to decide how far to pursue ancillary testing to feel comfortable with the diagnosis. Rex B. Villegas, O.D. West Los Angeles VA Healthcare Center Los Angeles, California
Variables associated with the incidence of infantile esotropia Regarding my article, “Variables associated with the incidence of infantile esotropia” (Optometry 2007;78(1):534541), we inadvertently listed Dr. Shannon Toomey as a coauthor, when she
actually only provided data collection assistance which should be acknowledged. We would appreciate it if you would issue a note to this effect in a subsequent issue of the journal.
1529-1839/08/$ -see front matter © 2008 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2008.01.009
Archima Major, O.D. Major Eyecare Associates LLC Philadelphia, Pennsylvania
Functional visual loss: A diagnosis of exclusion I read with interest the recent article by Villegas RB and Ilsen PF, “Functional visual loss: A diagnosis of exclusion” (Optometry 2007;78:523-533). The authors have done an excellent job outlining and describing the wide variety and clinical presentation of patients with functional visual loss. I would, however, challenge the conclusion and title of the paper which indicates that functional visual loss is a diagnosis of exclusion. In fact, traditional teaching has held that functional visual loss is a positive diagnosis made by demonstrating physiologic impossibilities. There is no doubt that the prudent practitioner will want to rule out organic disease in many cases of suspected functional visual loss especially when clinical testing is confusing or inconclusive. It is also known that many patients will experience “functional overlay” of true organic
disease further confounding an accurate diagnosis. It would be inappropriate, however, in all cases of functional visual loss to subject patients to an exhaustive battery of expensive and potentially risky testing when the diagnosis is positively established by demonstrating physiologic visual impossibilities. In these cases, reassurance, psychiatric evaluation, and careful follow-up would be the most appropriate management. Christopher J. Quinn, O.D. Omni Eye Services Iselin, New Jersey
Authors’ reply While functional vision loss can certainly be suspected on routine exam based on the patient’s response to vi-
sual and ophthalmologic testing, it is still a diagnosis of exclusion. However, we are not advocating that every suspected patient undergo the full battery of ancillary tests, as certain tests and procedures may be tedious, inconvenient, and excessive (particularly radiological imaging and electrophysiological tests). Since functional vision loss encompasses a wide variety of conditions, diagnosing cases of the condition should be varied accordingly. Depending on the particular circumstances with the patient, it is up to the individual practitioner to decide how far to pursue ancillary testing to feel comfortable with the diagnosis. Rex B. Villegas, O.D. West Los Angeles VA Healthcare Center Los Angeles, California
Variables associated with the incidence of infantile esotropia Regarding my article, “Variables associated with the incidence of infantile esotropia” (Optometry 2007;78(1):534541), we inadvertently listed Dr. Shannon Toomey as a coauthor, when she
actually only provided data collection assistance which should be acknowledged. We would appreciate it if you would issue a note to this effect in a subsequent issue of the journal.
1529-1839/08/$ -see front matter © 2008 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2008.01.009
Archima Major, O.D. Major Eyecare Associates LLC Philadelphia, Pennsylvania