Blurred vision in a nine-year-old patient

The question: 

A nine-year-old female patient attends practice with her father after reporting sudden onset blurred vision in both eyes. She has good vision in both eyes, does not wear spectacles, and reports no pain. No flashes or floaters are reported. How do you proceed? 

OT’s panel says... 

Ceri Smith-Jaynes: Curiouser and curiouser. Much of this will depend on the answers to my questions: 

• How blurred is her vision? It could be 6/60 blurred or 6/6- blurred 
• When did it start and how quickly did it come on?  
• What is her distance and near vision?  
• Is it blurred, or is it double vision? I saw a seven-year-old recently who complained of ‘blurred’ vision when reading, but he had an intermittent esotropia at near 
• Is it still happening now? If so, is it getting worse? 
• Does it come and go? I feel like I’m seeing more tear film issues and accommodation problems in children than ever before 
• Any redness, itching, or discharge? 
• Any recent trauma? I saw a child with a preretinal haemorrhage at the macula from a football to the head – unlikely in both eyes, but you never know. 

She says ‘no pain,’ but has she been getting any headaches? We need to rule out the big things such as papilloedema, so I might ask about transient visual obscurations. 

It could be refractive error. Is dad wearing spectacles? Are other family members myopic? I may reach for the cyclopentolate if I can’t find anything obvious. Check retinoscopy reflex quality and dynamic retinoscopy.  

What had the patient been doing before the blur started? I saw an 11-year-old recently with blurred vision on waking the day before. It had lasted a day, but everything was normal when I examined her. After digging a bit deeper, it transpired she had been sleeping in a beaded eye mask; there had been a TikTok trend about ameliorating puffy eyes. I think she had temporarily squashed her cornea. This only emerged at the end of the sight test – perhaps I could have delved deeper on history and symptoms.  

Many years ago, I saw a teenager with photokeratitis who blamed it on an ultraviolet lamp in physics class. I did wonder whether she had been using a sunbed without admitting it. I said her mother should have a word with the physics teacher and left it at that.  

I’ll also be asking about general health and medications; there could be some clues there.  

Visual fields: although I don’t do this routinely, children can often manage this test, and I may need to look for rare things like brain tumours or juvenile glaucoma.     

Ankur Trivedi: As ever, a great first answer from Ceri, which has covered a lot of my thinking. 

If all findings are normal with no issues to be found, sometimes it may be ‘malingering.’ I believe the preferred phrasing now is ‘functional vision loss,’ ’non-organic vision loss,’ or within the spectrum of ‘conversion disorder.’ All of these are a diagnosis made by exclusion. As detailed already, we need to confirm normality or other wise of. This is not an exhaustive list, however when looking for an abnormality I would cover:  

• A detailed history and symptoms 
• Vision and refraction  
• Binocular vision status and investigation 
• Ocular examination, both internal and external. 

In cases of suspected non-organic vision loss, it is useful to use techniques that may give results that are confounding or unexpected, eg failing the test colour vision plate on a colour vision test plate or page (such as Plate 1 on Ishihara), or improvement in vision or visual acuity with no power or plano lenses. Visual field examination can provide unusual visual field loss patterns, such as ‘cloverleaf’ visual fields.  

One child I saw a few years ago somehow always reported a number one higher or lower than the actual number on the page for Ishihara. He admitted to me afterwards that he thought this was a way to ensure he got spectacles, to be like his elder brother.  

If such an issue is suspected, it needs very careful handling with the patient and her father. There may be other issues at play which may be causing a concern for the patient from a family or school perspective. The patient may not be aware that they are suffering from a functional vision loss.  

Even if, as per Ceri’s consideration, some findings of retinal haemorrhage are detected, the clinician needs to satisfy themselves that the history provided by the patient and parent matches the injury. There is a safeguarding question that is uncomfortable but necessary to be considered. 

It shouldn’t be a common occurrence, but in the case of a child with visual loss erring on the side of caution is appropriate

Kevin Wallace: This is an interesting case. I agree with what Ceri and Ankur have said so far. The difficulty with these sorts of presentations is that significant pathology in children is rare – most children we see will be healthy. But it’s important to remember that it does happen, and often the initial presenting symptoms are like this. If the visual acuity doesn’t make sense, one of the first things I do is check it at a shorter distance – that can catch out a child trying to show that they have worse vision than they actually do. They’ll often read the same line even at half the distance, which clearly doesn’t make sense.  

I would definitely want to know about any symptoms that could indicate a neurological cause or trauma. Children will often shrug off something like a sports injury, which an adult would report. Visual fields and a thorough examination of the internal eye are vital to rule out some serious problems. If in doubt, equivocal results need to be followed up promptly and a low threshold for referral is required.   

If I can’t find a reason for the reduced vision, I would refer to paediatric ophthalmology with a report saying what they presented with and the results of my investigations and asking them to investigate – with the appropriate urgency for sudden onset visual loss if that’s the case. It shouldn’t be a common occurrence, but in the case of a child with visual loss erring on the side of caution is appropriate.