Nonorganic Vision Loss in Ophthalmic Practice: Diagnostic Frameworks, Differential Considerations, and Evidence-Based Management
Abstract
Background: Nonorganic vision loss (NOVL), also termed functional or psychogenic vision loss, represents visual impairment without sufficient structural or physiological pathology to explain the reported deficit. It poses diagnostic and management challenges due to its heterogeneous presentation and overlap with organic and psychiatric conditions.
Aim: To review the diagnostic frameworks, differential considerations, and evidence-based management strategies for NOVL in ophthalmic practice.
Methods: A comprehensive literature-based synthesis was conducted, integrating ophthalmic, neuro-ophthalmic, and psychosocial perspectives. The review emphasizes systematic evaluation, exclusion of organic disease, and multidisciplinary management principles.
Results: NOVL accounts for a clinically significant proportion of vision loss presentations across age groups, with prevalence estimates ranging from 16% in adults with ocular motor disorders to nearly 50% in pediatric cohorts. Etiology is multifactorial, involving psychogenic mechanisms (conversion disorder), symptom amplification, trauma-related pathways, and sociocultural influences. Diagnostic hallmarks include discordance between subjective complaints and objective findings, preserved automatic visual responses, and physiologically implausible patterns on visual field testing. Management centers on empathetic reassurance, patient education, and psychological referral, with cognitive-behavioral therapy and structured follow-up improving outcomes. Prognosis is generally favorable when NOVL is recognized early and addressed through a biopsychosocial approach.
Conclusion: NOVL is a genuine and disabling condition requiring careful exclusion of organic pathology, sensitive communication, and integrated care. Early recognition and multidisciplinary intervention reduce unnecessary investigations, mitigate distress, and support functional recovery.
Full text article
References
Broderick KM, Ableman TB, Weber ED, Enzenauer RW, Wain HJ, Wroblewski KJ. Non-organic Vision Loss in the Afghanistan and Iraq Conflicts. Neuro-ophthalmology (Aeolus Press). 2017 Aug:41(4):175-181. doi: 10.1080/01658107.2017.1295998.
Murcia-Belmonte V, Erskine L. Wiring the Binocular Visual Pathways. International journal of molecular sciences. 2019 Jul 4:20(13):. doi: 10.3390/ijms20133282.
Raviskanthan S, Wendt S, Ugoh PM, Mortensen PW, Moss HE, Lee AG. Functional vision disorders in adults: a paradigm and nomenclature shift for ophthalmology. Survey of ophthalmology. 2022 Jan-Feb:67(1):8-18. doi: 10.1016/j.survophthal.2021.03.002.
Edwards MJ, Yogarajah M, Stone J. Author Correction: Why functional neurological disorder is not feigning or malingering. Nature reviews. Neurology. 2023 Jun:19(6):384. doi: 10.1038/s41582-023-00821-2
Chen CS, Lee AW, Karagiannis A, Crompton JL, Selva D. Practical clinical approaches to functional visual loss. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2007 Jan:14(1):1-7
Sharpe M, Walker J, Williams C, Stone J, Cavanagh J, Murray G, Butcher I, Duncan R, Smith S, Carson A. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology. 2011 Aug 9:77(6):564-72. doi: 10.1212/WNL.0b013e318228c0c7.
Daniel MC, Coughtrey A, Heyman I, Dahlmann-Noor AH. Medically unexplained visual loss in children and young people: an observational single site study of incidence and outcomes. Eye (London, England). 2017 Jul:31(7):1068-1073. doi: 10.1038/eye.2017.37.
Mursch-Edlmayr AS, Mojon D, Bolz M. [Testing and approach when non-organic visual loss is suspected]. Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft. 2018 Jan:115(1):77-87. doi: 10.1007/s00347-017-0628-2.
van Impelen A, Merckelbach H, Jelicic M, Niesten IJM, Campo JÀ. Differentiating Factitious from Malingered Symptomatology: the Development of a Psychometric Approach. Psychological injury and law. 2017:10(4):341-357. doi: 10.1007/s12207-017-9301-y.
Duddu V, Isaac MK, Chaturvedi SK. Somatization, somatosensory amplification, attribution styles and illness behaviour: a review. International review of psychiatry (Abingdon, England). 2006 Feb:18(1):25-33
Köteles F, Witthöft M. Somatosensory amplification - An old construct from a new perspective. Journal of psychosomatic research. 2017 Oct:101():1-9. doi: 10.1016/j.jpsychores.2017.07.011.
Bass C, Wade DT. Malingering and factitious disorder. Practical neurology. 2019 Apr:19(2):96-105. doi: 10.1136/practneurol-2018-001950.
Takahashi M, Kunikata H, Kato K, Kawakami A, Nakazawa T. Familial Background Factors And Their Association With Non-Organic Visual Loss. Clinical ophthalmology (Auckland, N.Z.). 2019:13():2059-2061. doi: 10.2147/OPTH.S212365.
Somers A, Casteels K, Van Roie E, Spileers W, Casteels I. Non-organic visual loss in children: prospective and retrospective analysis of associated psychosocial problems and stress factors. Acta ophthalmologica. 2016 Aug:94(5):e312-6. doi: 10.1111/aos.12848.
Scarpina F, Melzi L, Castelnuovo G, Mauro A, Marzoli SB, Molinari E. Explicit and Implicit Components of the Emotional Processing in Non-organic Vision Loss: Behavioral Evidence About the Role of Fear in Functional Blindness. Frontiers in psychology. 2018:9():494. doi: 10.3389/fpsyg.2018.00494.
Bennett K, Diamond C, Hoeritzauer I, Gardiner P, McWhirter L, Carson A, Stone J. A practical review of functional neurological disorder (FND) for the general physician. Clinical medicine (London, England). 2021 Jan:21(1):28-36. doi: 10.7861/clinmed.2020-0987.
Egan RA, LaFrance WC Jr. Functional Vision Disorder. Seminars in neurology. 2015 Oct:35(5):557-63. doi: 10.1055/s-0035-1563580.
Hallett M, Aybek S, Dworetzky BA, McWhirter L, Staab JP, Stone J. Functional neurological disorder: new subtypes and shared mechanisms. The Lancet. Neurology. 2022 Jun:21(6):537-550. doi: 10.1016/S1474-4422(21)00422-1.
Dhanji S, Lawlor M. Functional visual loss. Current opinion in neurology. 2017 Apr:30(2):200-205. doi: 10.1097/WCO.0000000000000423.
Hamilton R, Bach M, Heinrich SP, Hoffmann MB, Odom JV, McCulloch DL, Thompson DA. VEP estimation of visual acuity: a systematic review. Documenta ophthalmologica. Advances in ophthalmology. 2021 Feb:142(1):25-74. doi: 10.1007/s10633-020-09770-3.
McBain VA, Robson AG, Hogg CR, Holder GE. Assessment of patients with suspected non-organic visual loss using pattern appearance visual evoked potentials. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2007 Apr:245(4):502-10
Orrù G, Ordali E, Monaro M, Scarpazza C, Conversano C, Pietrini P, Gemignani A, Sartori G. Reconstructing individual responses to direct questions: a new method for reconstructing malingered responses. Frontiers in psychology. 2023:14():1093854. doi: 10.3389/fpsyg.2023.1093854.
Grattan-Smith PJ, Dale RC. Pediatric functional neurologic symptoms. Handbook of clinical neurology. 2016:139():489-498. doi: 10.1016/B978-0-12-801772-2.00040-0.
Mechrgui M, Kanani S. The Ophthalmic Side Effects of Topiramate: A Review. Cureus. 2022 Aug:14(8):e28513. doi: 10.7759/cureus.28513.
Williams R, Hui A. Common systemic medications that every optometrist should know. Clinical & experimental optometry. 2022 Mar:105(2):149-156. doi: 10.1080/08164622.2021.1945409.
Schwarzbach M, Schwartze P. [Induction of optokinetic nystagmus in infants and young children by a horizontally, diagonally or vertically moving striped pattern]. Padiatrie und Grenzgebiete. 1991:30(3):167-82
Robinson DA. Neurophysiology of the optokinetic system. Progress in brain research. 2022:267(1):251-269. doi: 10.1016/bs.pbr.2021.10.012.
Anderson AJ, Shuey NH, Wall M. Rapid confrontation screening for peripheral visual field defects and extinction. Clinical & experimental optometry. 2009 Jan:92(1):45-8. doi: 10.1111/j.1444-0938.2008.00280.x.
Frisén L. Identification of functional visual field loss by automated static perimetry. Acta ophthalmologica. 2014 Dec:92(8):805-9. doi: 10.1111/aos.12405.
Levy AH, McCulley TJ, Lam BL, Feuer WJ. Estimating visual acuity by character counting using the Snellen visual acuity chart. Eye (London, England). 2005 Jun:19(6):622-4
O'Connor AR, Tidbury LP. Stereopsis: are we assessing it in enough depth? Clinical & experimental optometry. 2018 Jul:101(4):485-494. doi: 10.1111/cxo.12655. E
Fanlo Zarazaga A, Gutiérrez Vásquez J, Pueyo Royo V. Review of the main colour vision clinical assessment tests. Archivos de la Sociedad Espanola de Oftalmologia. 2019 Jan:94(1):25-32. doi: 10.1016/j.oftal.2018.08.006.
Bennett JL, Costello F, Chen JJ, Petzold A, Biousse V, Newman NJ, Galetta SL. Optic neuritis and autoimmune optic neuropathies: advances in diagnosis and treatment. The Lancet. Neurology. 2023 Jan:22(1):89-100. doi: 10.1016/S1474-4422(22)00187-9.
Somers LP, Bosten JM. Screening for mild anomalous trichromacy using the Ishihara plates test. Journal of the Optical Society of America. A, Optics, image science, and vision. 2023 Mar 1:40(3):A208-A219. doi: 10.1364/JOSAA.476536.
Invernizzi A, Cozzi M, Staurenghi G. Optical coherence tomography and optical coherence tomography angiography in uveitis: A review. Clinical & experimental ophthalmology. 2019 Apr:47(3):357-371. doi: 10.1111/ceo.13470.
Onofrj M, Ajdinaj P, Digiovanni A, Malek N, Martinotti G, Ferro FM, Russo M, Thomas A, Sensi SL. Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources? Frontiers in psychiatry. 2023:14():1120981. doi: 10.3389/fpsyt.2023.1120981.
Phansalkar R, Lockman AJ, Bansal S, Moss HE. Management of Functional Vision Disorders. Current neurology and neuroscience reports. 2022 Apr:22(4):265-273. doi: 10.1007/s11910-022-01191-w.
Gilmour GS, Nielsen G, Teodoro T, Yogarajah M, Coebergh JA, Dilley MD, Martino D, Edwards MJ. Management of functional neurological disorder. Journal of neurology. 2020 Jul:267(7):2164-2172. doi: 10.1007/s00415-020-09772-w.
Ricca AM, Han IC, Sohn EH. Stargardt disease masquerades. Current opinion in ophthalmology. 2021 May 1:32(3):214-224. doi: 10.1097/ICU.0000000000000750.
Tsang SH, Sharma T. Stargardt Disease. Advances in experimental medicine and biology. 2018:1085():139-151. doi: 10.1007/978-3-319-95046-4_27.
Petzold A, Fraser CL, Abegg M, Alroughani R, Alshowaeir D, Alvarenga R, Andris C, Asgari N, Barnett Y, Battistella R, Behbehani R, Berger T, Bikbov MM, Biotti D, Biousse V, Boschi A, Brazdil M, Brezhnev A, Calabresi PA, Cordonnier M, Costello F, Cruz FM, Cunha LP, Daoudi S, Deschamps R, de Seze J, Diem R, Etemadifar M, Flores-Rivera J, Fonseca P, Frederiksen J, Frohman E, Frohman T, Tilikete CF, Fujihara K, Gálvez A, Gouider R, Gracia F, Grigoriadis N, Guajardo JM, Habek M, Hawlina M, Martínez-Lapiscina EH, Hooker J, Hor JY, Howlett W, Huang-Link Y, Idrissova Z, Illes Z, Jancic J, Jindahra P, Karussis D, Kerty E, Kim HJ, Lagrèze W, Leocani L, Levin N, Liskova P, Liu Y, Maiga Y, Marignier R, McGuigan C, Meira D, Merle H, Monteiro MLR, Moodley A, Moura F, Muñoz S, Mustafa S, Nakashima I, Noval S, Oehninger C, Ogun O, Omoti A, Pandit L, Paul F, Rebolleda G, Reddel S, Rejdak K, Rejdak R, Rodriguez-Morales AJ, Rougier MB, Sa MJ, Sanchez-Dalmau B, Saylor D, Shatriah I, Siva A, Stiebel-Kalish H, Szatmary G, Ta L, Tenembaum S, Tran H, Trufanov Y, van Pesch V, Wang AG, Wattjes MP, Willoughby E, Zakaria M, Zvornicanin J, Balcer L, Plant GT. Diagnosis and classification of optic neuritis. The Lancet. Neurology. 2022 Dec:21(12):1120-1134. doi: 10.1016/S1474-4422(22)00200-9.
Patel HR, Margo CE. Pathology of Ischemic Optic Neuropathy. Archives of pathology & laboratory medicine. 2017 Jan:141(1):162-166. doi: 10.5858/arpa.2016-0027-RS.
Liu W, Liu S, Li P, Yao K. Retinitis Pigmentosa: Progress in Molecular Pathology and Biotherapeutical Strategies. International journal of molecular sciences. 2022 Apr 28:23(9):. doi: 10.3390/ijms23094883.
Leung DYL, Tham CC. Normal-tension glaucoma: Current concepts and approaches-A review. Clinical & experimental ophthalmology. 2022 Mar:50(2):247-259. doi: 10.1111/ceo.14043.
Volpe NJ, Rizzo JF 3rd, Lessell S. Acute idiopathic blind spot enlargement syndrome: a review of 27 new cases. Archives of ophthalmology (Chicago, Ill. : 1960). 2001 Jan:119(1):59-63
Hamed LM, Glaser JS, Gass JD, Schatz NJ. Protracted enlargement of the blind spot in multiple evanescent white dot syndrome. Archives of ophthalmology (Chicago, Ill. : 1960). 1989 Feb:107(2):194-8
Newcomb RD. Acute, idiopathic blind spot enlargement syndrome. Optometry and vision science : official publication of the American Academy of Optometry. 2000 Apr:77(4):178-87
Volpe NJ, Rizzo JF 3rd. Retinal disease in neuro-ophthalmology: paraneoplastic retinopathy and the big blind spot syndrome. Seminars in ophthalmology. 1995 Sep:10(3):234-41
Tsang SH, Sharma T. Acute Zonal Occult Outer Retinopathy (AZOOR) and Related Diseases. Advances in experimental medicine and biology. 2018:1085():233-237. doi: 10.1007/978-3-319-95046-4_49.
Agarwal N, Garg G, Pal AK, Dubey P, Garg A, Dewan P. Sudden-Onset Bilateral Blindness in a Young Girl Receiving Parenteral Nutrition: Case Report and Review of Literature. JPEN. Journal of parenteral and enteral nutrition. 2017 Sep:41(7):1240-1244. doi: 10.1177/0148607115601997.
Chen JJ, Chang HF, Hsu YC, Chen DL. Anton-Babinski syndrome in an old patient: a case report and literature review. Psychogeriatrics : the official journal of the Japanese Psychogeriatric Society. 2015 Mar:15(1):58-61. doi: 10.1111/psyg.12064.
Pula JH, Yuen CA. Eyes and stroke: the visual aspects of cerebrovascular disease. Stroke and vascular neurology. 2017 Dec:2(4):210-220. doi: 10.1136/svn-2017-000079.
Dermarkarian CR, Kini AT, Al Othman BA, Lee AG. Neuro-Ophthalmic Manifestations of Intracranial Malignancies. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society. 2020 Sep:40(3):e31-e48. doi: 10.1097/WNO.0000000000000950.
Tsang SH, Sharma T. Progressive Cone Dystrophy and Cone-Rod Dystrophy (XL, AD, and AR). Advances in experimental medicine and biology. 2018:1085():53-60. doi: 10.1007/978-3-319-95046-4_12.
Santodomingo-Rubido J, Carracedo G, Suzaki A, Villa-Collar C, Vincent SJ, Wolffsohn JS. Keratoconus: An updated review. Contact lens & anterior eye : the journal of the British Contact Lens Association. 2022 Jun:45(3):101559. doi: 10.1016/j.clae.2021.101559.
Paz Filgueira C, Sánchez RF, Issolio LA, Colombo EM. Straylight and Visual Quality on Early Nuclear and Posterior Subcapsular Cataracts. Current eye research. 2016 Sep:41(9):1209-15. doi: 10.3109/02713683.2015.1101139.
Stramkauskaitė A, Povilaitytė I, Glebauskienė B, Liutkevičienė R. Clinical Overview of Leber Hereditary Optic Neuropathy. Acta medica Lituanica. 2022:29(1):9-18. doi: 10.15388/Amed.2022.29.1.19.
Dysli M, Rückert R, Munk MR. Differentiation of Underlying Pathologies of Macular Edema Using Spectral Domain Optical Coherence Tomography (SD-OCT). Ocular immunology and inflammation. 2019:27(3):474-483. doi: 10.1080/09273948.2019.1603313.
Rahimy E, Sarraf D. Paraneoplastic and non-paraneoplastic retinopathy and optic neuropathy: evaluation and management. Survey of ophthalmology. 2013 Sep-Oct:58(5):430-58. doi: 10.1016/j.survophthal.2012.09.001.
Lee EK, Lee SY, Ma DJ, Yoon CK, Park UC, Yu HG. RETINITIS PIGMENTOSA SINE PIGMENTO: Clinical Spectrum and Pigment Development. Retina (Philadelphia, Pa.). 2022 Apr 1:42(4):807-815. doi: 10.1097/IAE.0000000000003367.
Vaphiades MS, Kline LB. Optic neuritis. Comprehensive ophthalmology update. 2007 Mar-Apr:8(2):67-75; discussion 77-8
Chiang MC, Dumitrascu OM, Chhabra N, Chiang CC. Migraine with Visual aura and the Risk of Stroke- a Narrative Review. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2021 Nov:30(11):106067. doi: 10.1016/j.jstrokecerebrovasdis.2021.106067.
Feinstein A. Conversion Disorder. Continuum (Minneapolis, Minn.). 2018 Jun:24(3, BEHAVIORAL NEUROLOGY AND PSYCHIATRY):861-872. doi: 10.1212/CON.0000000000000601.
Löwe B, Levenson J, Depping M, Hüsing P, Kohlmann S, Lehmann M, Shedden-Mora M, Toussaint A, Uhlenbusch N, Weigel A. Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis. Psychological medicine. 2022 Mar:52(4):632-648. doi: 10.1017/S0033291721004177.
van Genderen MM, de Wit GC, Riemslag FC. [Functional vision disorder: timely examination pays off]. Nederlands tijdschrift voor geneeskunde. 2016:160():A9656
Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ (Clinical research ed.). 2022 Jan 24:376():o64. doi: 10.1136/bmj.o64.
Espay AJ, Aybek S, Carson A, Edwards MJ, Goldstein LH, Hallett M, LaFaver K, LaFrance WC Jr, Lang AE, Nicholson T, Nielsen G, Reuber M, Voon V, Stone J, Morgante F. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA neurology. 2018 Sep 1:75(9):1132-1141. doi: 10.1001/jamaneurol.2018.1264.
Authors
Copyright (c) 2025 Suleman Abdu Alhunishi, Bashayr Mousa Mohammed Ageeli, Maram Hussin Mohammed Banajiah, Mohammed Obaid A Alanazi, Ashwaq Rabea Alabeeri, Fahad Abdullah Alahmadi, Wafaa Mohammed Alharbi, Omar Nafel Alharbi, Shujaa Murdhi Alrasheedi, Khalid Khlil Galfan Kamli, Khard Riyadh Mohammed H, Saleh Abdullah Alshaya, Waleed Saad Saeed Al Tawman
This work is licensed under a Creative Commons Attribution 4.0 International License.