Visual dysfunction in retinal and optic nerve disease.

Visual perceptions seen with retinal and optic nerve disease may overlap with those resulting from retrochiasmal disorders. A few disorders typically present with distinctive perceptions, but the majority have less specific symptoms. Features include whether or not the visual phenomena are negative or positive, monocular or binocular, and the location and form of any deficits. Among negative phenomena, transient visual loss usually is the result of ischemic disease, but particular precipitants may suggest demyelination or photoreceptor degeneration. The pattern and location of visual field defects may help localize disorders to the level of the macula, papillomacular or other inner retina nerve fiber bundles, optic nerve, or chiasm. Altered brightness perception may point to optic nerve or photoreceptor disease. Decreased acuity is among the most common and least specific symptoms, but association with other symptoms may help to narrow the differential diagnosis. Dyschromatopsia points to either a photoreceptor or optic nerve pathologic condition (Table 7). Among positive phenomena, hallucinations resulting from anterior visual system disorders typically are unformed, although deafferentation of retrochiasmal pathways may produce formed hallucinations. The common "floaters" frequently are benign, but occasionally herald more concerning disorders. Various types of photopsias commonly occur with vitreal disorders or photoreceptor disorders. Macular disease typically leads to distortions of the central visual field, and other particular disorders lead to a host of characteristic distortions of color, form, or brightness. Careful attention to the ophthalmologic examination, visual fields, and subtle variance in symptomatology also help to distinguish among various disorders.