Streff syndrome (also known as non-malingering syndrome) is a functional vision problem that involves problems with focusing, eye teaming and eye movments both fast and slow (saccades and pursuits). Authors such as Leonard Press note this syndrome can be considered a form of amblyopia of an involuntary, psychogenic nature.
Amblyopia is a condition of underdeveloped vision. Findings of underdeveloped vision can be considered a constellation (grouping) of findings that include lowered visual acuity, decreased accuracy and ability of ocular movements such as pursuits (slow eye movements) and saccades (fast eye movements), decreased focusing abilities and decreased visual processing skills. Decreases in stereopsis (3D vision / depth perception) and restrictions in visual field (tunnel vision) can be measured clinically. Most cases develop as a result of an eye turn (strabismus) or undercorrected refractive error. Amblyopia can occur in 2.5% of the population, making it responsible for more loss of vision than all ocular diseases and trauma combined.
Streff syndrome is a different type of amblyopia labeled psychogenic. This type is under-reported in the medical literature. Psychogenic means the origin is in the mind or more accurately in the parts of the brain that process vision. Psychogenic amblyopia can involve voluntary and involuntary types. Voluntary psychogenic amblyopia is also known as malingering – a process of faking a condition for some type of gain. Involuntary psychogenic amblyopia involves vision and vision processing problems that occur in a patient who is not malingering. Their problem is real, measurable and not being faked for some type of gain or attention. There is no organic base for the problem meaning that there are no observed structural or anatomic anomaly that can account for the problem. Saying that a problem is not organic however does not account for possible genetic, biochemical, electrophysiological or other abnormalities that may be present but for which we do not have the technology or background to identify them. The word functional means that the normal expected work or function that a process is supposed to offer (such as correct focusing) does not occur.
Streff syndrome is believed to develop as a result of stress. Hans Selye classifies stress as eustress – stress affiliated with change for the better such as marriage, getting an A on a test, being accepted into college or distress – stress affiliated with change for the worse such as divorce, family problems, substance abuse, emotional abuse, health problems. A reaction from too much stress can include behaviors that trigger a person’s alarm mode especially if there is to0 much stress leading to an overload.
A diagnostic pattern has been described for patients susceptible to Streff syndrome.
- Prepubescent or early pubescent ages 10 – 14
- Females more frequent than males
- Visual acuity worse than 20/20 to 20/200
- Visual skills problems in ocular movements, ocular focusing, visual information processing.
Symptoms noticed by patients, parents and teachers can include: a sudden decrease in academic performance, lack of desire to pursue homework, increased errors on homework, blurred vision at distance and at near, blurred vision of varying amounts which can come and go but usually stay blurry and headaches.
Sometimes the eye care professional can elicit a recent history of family stress, social stress, recent relocation.
The main clinical treatment of this condition is the use of a low plus eyewear prescription. This may be in the form of reading glasses or a multifocal. The effect of this prescription reduces the visual stress by just enough to allow the visual system to re-engage, organize and process information efficiently. Results are usually quickly obtained with improvements seen within a few weeks. Some cases may require vision therapy to improve eye movements and focusing. In cases unresponsive, eye care professionals should always rule out organic pathology both at the time of the initial diagnosis and later on.
In 1962, Dr John Streff first published a description of this condition. Articles in the optometric literature are more numerous than ophthalmological literature. This condition needs more research. The condition is considered functional in nature. Functional means no organic pathology exists but the software programming of the visual system is inefficient or not working as it should.
More Information: Streff Syndrome.pdf
(an information pamphlet written by Paul Harris, OD on this condition)
Much of this information is adapted from: Press, Leonard. Applied Concepts in Vision Therapy, St. Louis: Mosby 1997
Cook, Douglas T & Maples, WC. NSUOCO Vision Therapy Pocket Reference, Tahlequah: SITE 1994
Kevin Cline
// Jan 22, 2009 at 2:43 pm
Doug,
Here are a few comments: I alwasys thought of Streff Syndrome as a functional type of amblyopia. I think of Psychogenic Amblyopia the amblyopia that can result from stress due to emotional, physical, or sexual abuse. I have seen this type of amblyopia and it requires an appropriate referral to a psychologist or psychiatrist. Streff syndrome I always looked at as being due to stress as you have said but particularly due to nearpoint stress i.e. stress on the visual system due to having to due the socially compulsive biologically unacceptable task called reading or any extended nearpoint task.
Concerning diagnostic pattern–I also see near acuity worse than distance.
I do agree that you have to rule out organic pathology at the time of the initial diagnosis or see back in one month and if not improved refer out to pediatric ophthalmologist.
Dr Doug Cook
// Jan 27, 2009 at 11:27 am
I agree with the functional label too. I prefer this term in fact and use it in the office most of the time but avoided it during this article construction. I will update the text to reflect. I also see the near VA usually depressed as well. Thanks for your feedback.
David Kisling, O.D.
// Apr 29, 2009 at 4:46 pm
Just because of the demographics I am always concerned about sexual abuse when I see patients with functional vision loss. I have never had any luck getting parents to take their children to a therapist which adds to concerns of abuse. However, most kids I have seen do not show any behavioral signs of abuse which always adds to the mystery. It always seems difficult to really determine if the stress is visual or psychological. I do use low base in and any tint that will improve acuity. We frequently match tints for someone who has had an Irlen evaluation and even though it is the same only in appearance it has always worked.
Dr. Gurtisen
// Jun 16, 2009 at 8:37 pm
How does Streff Synd. relate to non malingering, Bilateral, collapsing, peripheral vision and clear central vision under high conditions of high stress and anxiety? Thanks for your comment
sophie gunn
// Aug 14, 2009 at 12:10 pm
my daughter was diagnosed with Streff Syndrome. She is 6 years old, which I understand is young for this type of diagnosis. i don’t see the correlation between her double and blurred vision to stress in her life so far. Unless she is extremely sensitive to everything around her and not able to cope with “normal” stress. She leaves in a loving family.
Dr Doug Cook
// Aug 14, 2009 at 1:05 pm
My best answer is “possibly.” There is a lot of information that needs to be asked and tests to be run. I would recommend a visit with a functional optometrist that has experience with this condition. You can find these specialists in a directory maintained by the College of Optometrists in Vision Development at this website http://covd.org/
Jackie
// Mar 23, 2010 at 6:00 pm
I was diagnosed with Streff Syndrome (by Dr. John Streff himself, believe it or not) when I was 15. I had been given a prescription when I was 8 that was just too strong for my eyes. My “stress” was not being able to see correctly. I was a completely adjusted and non-stressful person (I’m still not easily stressed). I did vision therapy with Dr. Streff and my vision has increased 20/200 to 20/125. My symptom was severe headaches. Be careful not to jump to conclusions about patients. My problems were purely visual and I did not need to see a psychiatrist. Eight years later, I still wear glasses but no more headaches!!!
Dr Doug Cook
// Mar 31, 2010 at 8:08 am
Thank you for your comment. In hundreds of cases, lens therapy and vision therapy has resolved all my cases. None of my Streff Syndrome cases persisted to the point I had to rethink and consider psychiatric counseling.