Streff Syndrome

[sco1styear]

I have an assignment where I'm supposed to get opinions of how different doctors would handle a certain situation, so any feedback would be greatly appreciated!

Scenario: 10yo female
CVC: Chalkboard and reading not clear for past 2-3 months,
grades dropping.
VA unaided distance: 20/80 OD,OS Near 20/100 OD,OS
Retinoscopy -0.50-1.00X090 20/70
-0.25-1.50X090 20/70
Subjective -1.75DS OD, OS 20/70
Near VA's 20/100 with either Rx
Pinhole, NI. Constricted peripheral fields by confrontation to 10degress, symmetrical
Ophthalmoscopy - within normal limits

You put on +0.50 spheres and after 20 minutes, VA's dist. and near are 20/30, fields open to 50 degrees.

You diagnose streff syndrome. How would you explain to the mom what is happening to her daughter and why? Also, when would you see her again, and what would you do?

Thanks for any input!

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[sco1styear]

So maybe I should be a little more specific...
1. Do you believe this is a real disorder?
2. Do you believe part of the problem is real and part is the patient malingering? If you believe they are malingering, how would you handle it?
3. Would you recommend the patient seeing a psychologist? And if so, how would you go about telling the patient?
Any opions would be greatly appreciated.

 

[xmattODx]

1. Do you believe this is a real disorder?

Yes

2. Do you believe part of the problem is real and part is the patient malingering? If you believe they are malingering, how would you handle it?

All of the problem is real. By definition you can't have a problem that is part real and part malingering.

3. Would you recommend the patient seeing a psychologist? And if so, how would you go about telling the patient?
Any opions would be greatly appreciated.

You haven't mentioned what is stressful in the patient's life. Is it serious? Simply a move away from friends? It's not entirely necessary for a patient to see a psychologist but it isn't a bad idea in some cases. Prescribe the low plus and expain to the patient, (actually usually the parent), that in times of stress our bodies respond in different ways and some people respond in a way that causes blurry vision.

 

[sco1styear]

You haven't mentioned what is stressful in the patient's life. Is it serious? Simply a move away from friends? It's not entirely necessary for a patient to see a psychologist but it isn't a bad idea in some cases. Prescribe the low plus and expain to the patient, (actually usually the parent), that in times of stress our bodies respond in different ways and some people respond in a way that causes blurry vision.

Thanks so much for replying!

I read that some doctors believe their actually is a problem but the student overexagerated how bad it really is.
I have also read to use vision therapy as well as low plus.
If you had this patient how would you manage them? When would you see them back next?

This is for a project we do with a professor. We are handed what I previously stated as far as info about the patient and our job is to research it and find out how other doctors would handle the situation.
We then meet back with the professor and she pretends to be the patient or parent and we must tell them what is wrong and what the plan of action is just as you would in real life at the end of the exam. So there is a chance that I may find out what the stress problem is when I am explaining the problem to her (just as you might in real life).

 

[xmattODx]

I read that some doctors believe their actually is a problem but the student overexagerated how bad it really is.

This is an aside but I think it is very dangerous to start thinking in this way. We need to just let go and believe whatever it is our patients are telling us. It is annyoing to have patients read the 20/400 line and say that is the best they can do, then scope at -0.75 DS OU and be 20/20, but their perception of blur is 20/400. The same can be said for Streff. This is non-malingering syndrome and, therefore, what ever it is the patient is telling us is the way they see their world.

I have also read to use vision therapy as well as low plus.
If you had this patient how would you manage them?

I come from a school of thought that believes the best vision therapy is lenses. That is, our most powerful VT tool is a set of lenses. I would prescribe the low plus as that, along with some personal growth on the part of the patient should take care of the problem with the least expense to the patient.

When would you see them back next?

Depends on the patient and their reaction to the patient education but probably 3 months.

Good luck on your assignment. It is important to get a feel for what is happening in the patient's life as Streff syndrome is predicated on some type of emotional stress.

 

[sco1styear]

Thanks so much!!!

 

[SCOALUM]

Just dont tell Dr. Anderson how cheezy this research project really seems, especially when she tells you at the end of your first quarter in school "Do you feel like a real doctor now?"

Streff is real. It is hard to explain though. I had an 11 year old girl today with it and she was really being honest. Scoped her and she was only +0.50 OU. She could only do 20/200 OD, OS. Her mom was crying while I stumbled over my thoughts trying to explain this. So I got online to figure out the actual way to describe it myself. This was stressful for me to diagnose and explain today. Let me know how doctor A says you should explain it. I assume this is her assignment, or maybe doctor eubanks? You wont get this patient often, diagnosis is not hard, but explaining it is.

Good luck. Take every assignment in school with a grain of salt. It is mostly cheesy and useless. Wish I could remember your cheesy answer to this question today with my patient though. So as much as I hated those assmts at SCO . . . take it for what it's worth.

Eye Doc

 

[sco1styear]

I had forgotten about this It seems like forever ago! It was actually an assignment from Dr. Harville (one of the video assignments), not Dr. Anderson ("do you appreciate that?" ).

I believe I just said something like..."your daughter has what is called streff syndrome. It is usually associated with stress."....and I rx'ed low plus and recommended her talking to a counselor, such as the school counselor (since I was pretty sure this pt could not afford to pay for a counselor).

 

[DrEyeBall]

Please do yourself a favor and :

1. Read the original paper written by Dr. Streff on this disorder
2. Put aside what you have been taught in class about this and think critically about it for a moment.

Streff described a "syndrome" of "functional amblyopia". His description leads one the believe that amblyopia is not "organic". Amblyopia is of course organic. There are real pathologic changes that occur in the brain of people with amblyopia. These have been shown on functional MRI, PET scans and on histologic examinations of affected brains.

Streff uses many suggestions and "theories" to discuss the so called "findings" of his syndrome. There is no proof for these. These patients also respond to plano lenses and when the parents are given reassurance as to what is happening, these patients get better.

What you are describing is a functional disorder. While functional disorders may include malingering, they are not he same thing. Malingering is a functional disorder that provides a secondary gain. If this child claimed poor vision to avoid homework or bedtime, that would fit that description. These children may very well believe they see poorly. However, they do not. Although Streff and others have suggested low plus lenses and VT as a treatment, parenatl reassurance works just fine and costs the family nothing more than your exam. In the rare case that this does not help, other support should be given.

Please don't accept this disease as what it is claimed to be because someone gave you a lecture on it and told you to believe it. Pull the literature, think for yourself and make your own conclusion.

 

[fjpod]

I've dealt with many of these kids over the years. Always girls ages 7-12. Ocassionally an older girl or woman. (Boys always present with forced blinking as if to show they can't see clearly, but they do usually read the chart).

If you can sort of predict that you have one during the case history, I have found a sure fire way to get a reliable visual acuity.

Instead of throwing up a snellen chart from 20/60 to 20/20 and saying "Read the smallest line that you can", or putting up a 20/200 letter and trying to work your way down the chart, put up an isolated line with no letters in it and say, " can you see the three little letters in this line?"...When the child stumbles and says no, you say, "well do you see two or three letters or, is it blank?". They will say it is blank. This tells you something right there. They can discern that there is a white line there with nothing in it. Can't do that with 20/200 vision.

Then put up a 20/10 line and ask them to read it. They usually won't. Then you ask, "well do you see any little black dots?, how many" They will usually answer these questions correctly. Again this tells you their acuity is much better than they would have you believe. Then progress up the chart line by line. They probably won't read 20/15 either. You could ask again how many letters they see. They will usually start to answer correctly. After the second or third 20/20 line they start reading because they figure they better start reading something soon before you declare them legally blind and send them off to a school for the blind. They don't realize that you have 3 or 4 20/20 lines. With everything isolated, they have no frame of reference of what is big and what is small. They think you are putting up progressively larger letters. When I change lines, I block their view of the chart by standing in front of them so that they lose their perspective of how big the previous letters were. Works every time. It's all in how you ask the questions.

I honestly don't know if these kids are just trying to get glasses or seeking parental attention, or both. I don't mean to dismiss Streff non-malingering syndrome, but I sense that the reason these kids respond to VT is the attention they get from it...and the fact that they want to get away from it (VT) lol, after a few weeks so they can go to dance lessons and the like. BTW, I am part of a large VT practice and so I believe in it and practice it regularly.

The point I am making here is there is a better way to take visual acuity in these cases than the way we usually do it.

 

[DrEyeBall]

These are good points. I would also point out the following:

Many of these patients fail their vision test in a similar way. Unlike someone who actually can not see the letters, they may read the letters and just read them incorrectly. This is atypical for a myope.

Also, you do not need to "prove" they are 20/20. You need to prove their complaints are not physiologic. Bring the patient closer to the chart. When they read the same level, you have proven their complaints are non-physiologic. Same thing with "tunnel fields". Although Streff suggests they are part of his syndrome, they are no such thing. There is no possible way these can actually occur. They are functional and have no organic basis.

I see many of these patients. they do just fine with some parental reassurance and nothing more

 

[ceresance]

I have an assignment where I'm supposed to get opinions of how different doctors would handle a certain situation, so any feedback would be greatly appreciated!

Scenario: 10yo female
CVC: Chalkboard and reading not clear for past 2-3 months,
grades dropping.
VA unaided distance: 20/80 OD,OS Near 20/100 OD,OS
Retinoscopy -0.50-1.00X090 20/70
-0.25-1.50X090 20/70
Subjective -1.75DS OD, OS 20/70
Near VA's 20/100 with either Rx
Pinhole, NI. Constricted peripheral fields by confrontation to 10degress, symmetrical
Ophthalmoscopy - within normal limits

You put on +0.50 spheres and after 20 minutes, VA's dist. and near are 20/30, fields open to 50 degrees.

You diagnose streff syndrome. How would you explain to the mom what is happening to her daughter and why? Also, when would you see her again, and what would you do?

Thanks for any input!

Stress results from the demands on a system being greater than the ability. Near vision stress is an example of this. The Streff syndrome and the Non-malingering syndrome is very real. Fortunately it usually responds well to demand reduction. This means such things a +.50 for near, or demand management such as frequent breaks from near activities or myopia development.
My job as a clinician is to fix problems. I have never found a child to malinger. If they "want" glasses it is because they understand there is a problem and they hope this will fix it.
Google Streff syndrome for more information.

 

[IndianaOD]

Streff Syndrome is a disorganization of sorts of the ambient and focal visual processing streams. You could also kind of think of it as magnocellular vs parvocellular. This syndrome is real and has caused countless unnecessary $5000 MRIs I am sure.

You are looking for reduced distance and near acuity binocularly. Decreased accommodation and loss of stereopsis. Severly reduced confrontation fields and poor responses on color testing. The patient usually presents with near vision difficulty, headaches, and recent decease in school performance.

Don't discount the treatment because its only 0.5 diopters. Small amounts of plus and adds can have enormous impact.

 

[spanisheyes]

I happen to have the very exact assignment and this has helped a lot, thanks

 

[JMU07]

I happen to have the very exact assignment and this has helped a lot, thanks

hahah. Mine is on optic neuritis and MS.. anyone want to give me any input on that? I have a 32 yo female who's had three episodes of blurry vision OD with pain on EOM movement. 20/80 VA's in that eye, with central scotoma. I've already diagnosed optic neuritis and need to tell her about the possibility of MS.

I think for me this is more about learning how to explain to the patient that something else could be wrong without being blunt or rude about it and less about explaining the details of both diseases. I've done my research on the connection between the two, but how would some of you go about sitting down with your patient and gently explaining to them the possibility of having MS?

(keep in mind these aren't real patients, they're assignments.. so no, we're not asking for medical advice.)