Sunglasses Syndrome: Definition and Clinical Significance
Sunglasses syndrome refers to the wearing of sunglasses indoors or in clinical settings without an obvious ophthalmic reason, which is highly predictive of nonorganic visual loss (NOVL) in neuro-ophthalmologic practice.
Clinical Features and Diagnostic Value
- The "sunglasses sign" has a high specificity (99.5%) for nonorganic visual loss in neuro-ophthalmologic settings 1
- Among patients wearing sunglasses in neuro-ophthalmology clinics, 79% are diagnosed with nonorganic visual loss 1
- The sensitivity of wearing sunglasses for NOVL is 46%, meaning nearly half of all NOVL patients present wearing sunglasses 1
Associated Characteristics
NOVL patients wearing sunglasses typically demonstrate at least one of the following characteristics (96.3% of cases):
- Highly positive review of systems
- Workers' compensation claims
- Disability claims
- Pending lawsuits related to visual complaints 1
Patients with legitimate organic neuro-ophthalmic disorders who wear sunglasses typically have clear ophthalmic explanations for doing so, such as:
- Photosensitivity from retinal disorders
- Photophobia from inflammatory conditions
- Protection following ocular surgery 1
Clinical Differentiation
- When evaluating a patient wearing sunglasses indoors, clinicians should determine if there is a legitimate ophthalmic reason for sunglasses use 1
- Absence of a clear ophthalmic explanation for sunglasses use should raise suspicion for nonorganic visual loss 1
- A thorough examination for other signs of nonorganic visual loss should be conducted when the sunglasses sign is present 1
Important Distinctions
It's important not to confuse sunglasses syndrome with other conditions where specialized eyewear may be used:
- Sagging eye syndrome - an age-related condition characterized by degeneration of the superior rectus-lateral rectus connective tissue band causing esotropia and diplopia 2
- Divergence insufficiency - characterized by esotropia that increases with distance fixation 2
- Therapeutic uses of tinted lenses - such as blue sunglasses for photosensitive epilepsy 3 or hemispatial sunglasses for unilateral spatial neglect 4
Clinical Implications
- Recognition of the sunglasses sign can help clinicians identify potential nonorganic visual loss early in the evaluation process 1
- When sunglasses syndrome is identified, further testing for nonorganic visual components should be performed 1
- Patients with legitimate reasons for wearing sunglasses indoors (photophobia, light sensitivity, etc.) should not be misdiagnosed with nonorganic visual loss 1
Management Considerations
- Address any underlying psychological factors that may be contributing to nonorganic visual symptoms 1
- Consider the potential for secondary gain (disability claims, lawsuits) in patients presenting with the sunglasses sign 1
- Document objective findings carefully to distinguish between organic and nonorganic visual complaints 1