Persistent Binocular Vision Loss

    • Enduring visual loss affecting both eyes
    • Causes
      • Optical disorder
      • Retinocortical disorder
      • Psychogenic ("non-organic") disorder
    • Vision impaired for distance viewing but not for reading = uncorrected myopia
    • Vision impaired for reading but not for distance viewing = uncorrected presbyopia
    • Ghost image or vision that improves with pinhole = optical (refractive or ocular media) disorder
    • Specks that lag behind eye movement = vitreous detachment or other vitreous debris
    • Black areas that do not lag behind eye movement = retinal surface lesions
    • Blank areas in the visual field (“scotomas”) = retinocortical disorder
    • Sparkling vision = retinopathy or visual cortex disorder
    • Patients whose eyes become misaligned may report blurred vision when they are really experiencing double vision; if covering either eye makes blurred vision disappear, it probably is double vision!
    • Follow these steps
      • Step 1: measure visual acuity
      • Step 2: perform the pinhole test; if it improves visual acuity, the patient probably has an uncorrected refractive error or ocular media imperfection
      • Step 3: perform refraction and biomicroscopy to confirm an optical cause; if you do not find an optical cause …
      • Step 4: perform the swinging flashlight pupil test, looking for a relative afferent pupil defect (RAPD), which would suggest an optic neuropathy or extensive retinopathy
      • Step 5: perform ophthalmoscopy to exclude optic disc or macular abnormalities, most of which will be visible; if the diagnosis remains uncertain…
      • Step 6: perform a formal visual field examination to establish the pattern of visual field loss, which may localize the lesion to the retina, optic nerve, optic chiasm or retrochiasmal visual pathway; if the diagnosis remains uncertain…
      • Step 7: perform ancillary studies, such as optical coherence tomography (OCT), fundus photography, fluorescein angiography, ultrasonography, electroretinography (ERG), or orbit/brain imaging
    • Pinhole, refraction, and biomicroscopy will diagnose most optical conditions
    • Ophthalmoscopy will diagnose most retinal conditions, but OCT and ERG improve sensitivity
    • History and visual field examination are helpful in localizing lesions of the retinocortical visual pathway, but brain imaging is often needed for diagnosis
    • Many conditions causing acute binocular visual loss require prompt treatment to prevent catastrophic outcomes
    • Some chronic conditions (refractive error, cataract, keratopathy, certain optic neuropathies) can be effectively treated

    Persistent Vision Loss

    Persistent Monocular Vision Loss Persistent Binocular Vision Loss