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Streff Syndrome

January 19th, 2009 · 21 Comments · Learning-Related Vision Problems, Vision Conditions, Vision Development

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 help 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.  Streff syndrome is considered an involuntary psychogenic amblyopia.     It’s considered a functional vision problem in otherwise healthy visual system.  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 and 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 or depression.  Some cases have been seen as a vision problem alongside post-traumatic stress disorders.  Treatment with lenses can help resolve the visual components involved.  Counseling and stress management may be needed if problems persist and social factors are identified.

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

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21 Comments so far ↓

  • Kevin ClineNo Gravatar

    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 CookNo Gravatar

    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.No Gravatar

    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. GurtisenNo Gravatar

    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 gunnNo Gravatar

    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 CookNo Gravatar

    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/

  • JackieNo Gravatar

    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 CookNo Gravatar

    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.

  • Liz FishNo Gravatar

    My son has just got a diagnosis of streff syndrome.
    He is 9. No history of abuse he comes from a loving family. He has been diagnosed dyslexic could they be related?

  • Dr Doug CookNo Gravatar

    I’m not aware of links between Streff Syndrome and Dyslexia. It would be possible for a child to have both without one causing the other.

  • JohnNo Gravatar

    My son has been diagnosed with Streff Syndrome. He is 11 and is on the autistc spectrum. He currently weras glasses fro reading. The diagnosis was made by an optician following just two tests with a recommendation of vision therapy. Is it normal to look to vision therapy at this stage in the diagnosis or should I persue more test for my son,

  • Dr Doug CookNo Gravatar

    Not knowing what the tests were and without more information, I would not be able to comment. Generic advice I can give if you are considering a second opinion would be to seek advice from board certified functional vision providers that have FCOVD or associate credentials. You can search for them at the website for the College of Optometrists in Vision Development at covd.org. Here’s a link. https://covdwp.memberpoint.com/WebPortal/BuyersGuide/ProfessionalSearch.aspx

  • Nic BoydNo Gravatar

    Thank you for the information. I am a psychologist and am currently seeing a client in consultation with a General Practitioner that I often work with. The patient’s GP believes that his ongoing vision problems stem from Streff Syndrome despite all clinical investigations returning as negative and treatment through correct eyewear having little, and possibly a negative effect. The GP feels that the patient has had indications of the syndrome since a very young age (2 years old). Is this a possible developmental pathway of the syndrome and can it occur in young adulthood (the patient is now aged 18)? Finally, does the syndrome follow a degenerative pattern if untreated or can its severity oscillate rapidly. Thank you for your reponses.

  • A Thought We’d Rather Not Have « The VisionHelp Blog

    [...] Advocacy — Len Press @ 4:44 pm Dr. Doug Cook has done a very nice job on his blog in putting together a synopsis about Streff Syndrome.  We often associate this with generalized [...]

  • HilaryNo Gravatar

    My son was diagnosed at age 8. We marked it up to stress and he wore a low powered lens and the condition disappeared in 2weeks. Will it return and should he do vision therapy?

  • Dr Doug CookNo Gravatar

    Most cases I’ve seen over my 20 year + career did not recur – a few have. I would recommend regular follow-up with his doctor as he/she recommmends.

  • Glenda SnowNo Gravatar

    Hi Dr Cook, I have an 8 yo (almost 9) daughter diagnosed with Streff Syndrome. We are in Sydney Australia. My daughter has been suffering stress and anxiety due to possibly the last few years of my husband and mine being very stressful. We are both Forensic Police and have being doing this career for just under 20years. I am currently writing a book on Child anxiety and a chapter is solely on Streff Syndrome. I have a Senior Optometrist that has agreed to write a chapter so the public can be informed correctly of the condition to give them knowledge and hopefully not giving them a diagnosis they can create about their children. I would appreciate any recommendation on the subject. I will also be setting up a website that families can chat on the forum. I will keep you informed if you are interested?

  • Dr Doug CookNo Gravatar

    Dear Glenda,
    I am glad you found someone that can help your daughter and can write a chapter on that topic for your book. As you have discovered, this topic does not have much information posted online yet. References I can mention include a good post by Paul Harris OD here in the USA, http://www.paulharrisod.com/non-malingering-syndrome.

    The College of Optometrists in Vision Development (http://www.covd.org/) is the premier organization in the USA for behavioral optometrists familiar with this condition. One resource from them is an original article by Dr. Streff on the diagnosis that bears his name. http://www.covd.org/Portals/0/OVD/42-2/OVD%2042-2%20Journal_article_streff_visualskills_web.pdf. A later issue of Optometry and Vision Development had many articles on Dr. Streff’s contribution to behavioral vision care http://www.covd.org/Home/OVDJournal/OVD422/tabid/320/Default.aspx.

    Another name more functionally based is Juvenile Bilateral Functional Amblyopia Syndrome or Non-Malingering Syndrome as Dr. Harris refers.

    The Australasian College of Behavioural Optometrists http://www.acbo.org.au/ is the analog to the COVD for your country. A quick review of their site didn’t reveal much yet but it would be the organization to consider for referring parents seeking care like you have gotten for your daughter.

    With more resources such as your book, you can help educate the public. I would be happy to include links when you have your site set up – let me know. I wish you success on your endeavor.

  • patientNo Gravatar

    I was diagnosed with Streff Syndrome at age 10. Some of the accts that I read from docs are quite offensive- outright asserting it to be all faking.I can tell you that it is not something I personally faked. I had about 3 yrs of vision therapy that included various occlusions and other things. Eventually my symptoms lessened. I would have a reoccurance in the sense that I had to deliberately occasionally use focusing skills that I learned in vision therapy. I would have the extreme blur, employ the muscular skill and my acuity increased. I never stopped wearing glasses. Now at 43 I am having perhaps a reoccurance where employing those skills isn’t enough. Still in the process of what is going on. PLEASE,PLEASE do not assume that all patients with this syndrom are fakers or attention seekers. I really needed to learn those focusing skills.

  • JessicaNo Gravatar

    I am a vision therapist and currently have a patient with Streff Sydrome and while she has made good progress, she is not where i would expect her to be visually. She sleeps an average of 4 hours a night. Are there any links to insomnia and Streff?

  • Dr Doug CookNo Gravatar

    A stress component can often be found in association with Streff’s syndrome. If present the stress itself could be a factor in insomnia.

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