Weakness or paralysis of accommodation sometimes occurs, primarily in children and young adults. Such patients may complain of an inability to read clearly even in the presence of an appropriate plus lens. Failure of a patient with normal distance vision to read despite appropriate near vision correction should alert the clinician to the possibility of a nonorganic condition.

Spasm of accommodation is observed with the syndrome of spasm of the near reflex. Patients may report blurred distance vision and often can produce 8–10 D of myopia. Refraction without and with cycloplegia during the period of spasm establishes the presence of the induced myopia.

Eyelid Position and Function

Ptosis

Eyelid “droop” from nonphysiologic causes can usually be distinguished by the position of the brow. In a patient with true ptosis, the brow is usually elevated as the patient tries to open the palpebral fissure. With orbicularis overactivity, the brow is lowered.

Patients who feign ptosis generally cannot simultaneously elevate the eye and maintain a drooping eyelid. Thus, with upward gaze, the ptosis will “resolve.” Often the patient will realize this and not cooperate. In such cases, the examiner can use his or her thumb to manually elevate the ptotic eyelid and the patient will then look upward. The examiner’s thumb is then slowly moved away. If the ptosis returns, the condition may well have an organic basis, but if it “resolves,” then it is nonorganic.

Blepharospasm

Nonorganic blepharospasm may be unilateral or bilateral and typically occurs in children or young adults. It may be triggered by an emotionally traumatic event and may cause nonorganic ptosis. Pressure over the supraorbital notch is often useful in raising the eyelids.

Management of the Patient With Nonorganic Complaints

Patients with nonorganic visual complaints are best managed with an understanding approach and words of encouragement. Confrontation is seldom of benefit to either the patient or the doctor. It is prudent to allow patients a graceful way out of the situation by reassuring them that their disorder, while unlikely to reflect a serious condition, is a problem that will resolve over time. Often, the symptoms will clear with 1 or 2 follow-up visits, and patients should be reassured of an “excellent prognosis.” This approach is usually more effective with children than adults. Children may be further encouraged through the prescription of “eye rest”—for example, by removing the “overuse of television.”

In patients with combined organic and nonorganic (nonorganic overlay) complaints, it is best to manage the organic problem and attempt to downplay the nonorganic portion. In some cases, consultation with a psychiatrist or psychologist may be warranted for an underlying psychological illness. Finally, it is always prudent to monitor a patient with what initially appears to be a nonorganic visual disturbance. Occasionally, an organic disorder becomes apparent later and can be managed appropriately.

Kathol RG, Cox TA, Corbett JJ, Thompson HS. Functional visual loss. Follow-up of 42 cases. Arch Ophthalmol.