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People with psychosomatic eye disorders may be inappropriately labelled as malingerers.[1] They may be missing out on emotional care offered to people with medically unexplained disorders in other parts of the body such as the back or stomach.[2] I will outline instances of two children who required two different approaches.

Case Study: Darren

Darren, a robust ten-year-old, arrived in the eye clinic complaining that his vision was deteriorating. He was a bright boy and his family looked worried. Darren had thorough medical assessments, and was found to have reduced distance vision (6/18 in both eyes). No medical cause for this sight loss was found.

When I tested him, I was able, with a variety of lenses, to establish that his visual acuity was in fact normal. What could be causing Darren’s visual distress? Standard orthoptic history taking involves making enquiries about the ocular history, signs and symptoms, family history, general health history and birth history. Here, however, I felt that some gentle queries about Darren’s family and home life might be illuminating.

Darren attended the eye clinic with his mother and father. It transpired his parents were divorced and had remarried. Darren lived with the stepfather he did not care for, and a new baby half-sister. The clinical presentation suggested that when Darren was unwell, it brought his parents together. Towards the end of the consultation, the mother volunteered that her father had had a neurological disease. On airing these difficult emotional issues, Darren then said “I see better”. He left the clinic with his vision normal and age-appropriate.

Attention to the general presentation of the child in the context of his family, and the willing, open engagement with the family, brought to light Darren’s concerns.

Understanding is not always so readily available, and people whose presentations suggest more complex psychological profiles may need referral to psychiatry or psychotherapy.

To this end I established contact with professionals in liaison psychiatry for specialist investigation of the influence of psychosocial factors. Inter-disciplinary liaison between eye and psychological professionals is a new departure, and the work was challenging. Eventually however, after many years, I was able to bring together professionals from these very different disciplines, and from this emerged The Mind’s Eye Clinic. One of the first people to benefit from this new liaison work was Lisa.

Case Study: Lisa

Lisa was the 12-year-old daughter of a well-known mother and an artist father. She came to the eye clinic complaining of seeing a veil in front of her eyes. Clinically she demonstrated normal vision. Extensive ophthalmological, orthoptic and neurological investigations, including scans, had failed to yield any ocular or medical reason for her visual disturbance.

The family could not offer any clues to the cause of Lisa’s visual difficulties, and they decided that they would like to pursue a psychological line of enquiry. I referred the child to a child psychiatrist colleague. Family meetings with the psychiatrist revealed Lisa’s feelings of pressure about the need to succeed. She also had ambivalent feelings about being the eldest child with five little brothers, the youngest of which was only five months. Furthermore she was the subject of extensive bullying at school about her famous mother, and she had not wanted to worry her busy parents about this. In addition, the bullying was unacknowledged by the school, and required the active intervention of both the parents and the psychiatrist to address it. Lisa’s sense of clarity of vision then returned, and she was discharged from the eye and psychiatric clinics.

Conclusion

This is a brief summary of two complex cases. It is suggested that professionals in eye clinics extend their gaze to an awareness of the emotional aspects of their patients. Middleton[3] has recommended joint management of cases of medically unexplained visual loss by both and eye and psychiatric professionals. Developing the necessary referral pathways from eye to psychiatric professionals is a matter of good clinical practice and not simply a matter of local interest.[4]

Names and other details have been changed to protect privacy.

References

1.    Hansen V C. What Do You Tell Parents About Why Their Child is Pretending Not to See? American Orthoptic Journal. 52: 23-29.  2002.
2.    Alexander F et al. Psychosomatic Specificity. University of Chicago Press. Chicago. ISBN-10: 0226673561 1968.
3.    Middleton EM. The Mind’s Eye: Psychological aspects of eye disorders Psychoanalytic Psychotherapy. 12 (2): 148-149 1998.
4.    Middleton EM, Sinason MDA and Davids Z   Blurred Vision Due to Psychosocial Difficulties: A Case Series. Middleton EM, Sinason MDA and Davids Z Eye advance online publication. 19 October 2007. (DOI 10.1038/sj.eye.6703009).

Acknowledgements

Liz Middleton would like to thank Dr Zaib Davids, Dr Michael Sinason, the Inman Trust, and The Eye and The Mind Society for their valued contributions to the development of The Mind’s Eye Clinic.