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ULY CLINIC

19 Septemba 2025, 04:22:35

Tunnel vision

Tunnel vision is a severe constriction of the visual field that leaves only a small central area of sight. Patients often describe it as looking through a tunnel or gun barrel. It may be unilateral or bilateral and usually develops gradually.

Tunnel vision is commonly caused by chronic open-angle glaucoma, advanced retinal degeneration, or retinal laser photocoagulation therapy. It can also be reported by malingerers but can be objectively verified through formal visual field examination by an ophthalmologist.

Pathophysiology

Chronic open-angle glaucoma: Progressive loss of retinal ganglion cells and optic nerve fibers causes gradual constriction of the peripheral visual field.
Retinal pigmentary degeneration: Hereditary disorders such as retinitis pigmentosa cause concentric annular scotomas, leading to progressive tunnel vision.
Retinal laser therapy: Laser photocoagulation for retinal detachment can cause iatrogenic peripheral field constriction.
Functional/malingering: Reported tunnel vision without physiologic basis; may be identified by inconsistent behavior.

History and Physical Examination

History

Onset (sudden vs gradual) and progression of peripheral vision loss.
Detailed description of what and how far the patient can see peripherally.
History of ocular disease, eye trauma, or corrective surgery.
Family history of hereditary retinal disorders or early-onset blindness.
Observe daily activities: patients with true tunnel vision may bump into objects, whereas malingerers typically avoid obstacles.

Physical Examination

Visual acuity and color vision testing.
Fundoscopy: check for optic disc pallor, narrowed retinal vessels, or pigmentary changes.
Tonometry: assess for elevated intraocular pressure (glaucoma).
Visual field testing: perimetry to quantify field constriction.
Observe gait and mobility for safety assessment.

Medical causes

Cause	Onset	Key Features	Associated Signs	Pathophysiology	Management
Chronic open-angle glaucoma	Gradual	Bilateral tunnel vision; late stage	Mild eye pain, halo vision, reduced visual acuity (esp. night)	Optic nerve damage from elevated intraocular pressure	Topical/systemic IOP-lowering agents, surgery, laser therapy, regular ophthalmologic follow-up
Retinal pigmentary degeneration (Retinitis pigmentosa)	Gradual, usually first/second decade	Annular scotoma → tunnel vision; night blindness	Pale optic disc, narrowed retinal vessels, eventual total blindness (by ~50 years)	Hereditary photoreceptor degeneration	Genetic counseling, low-vision aids, vitamin A supplementation (in select cases), protective eyewear
Laser photocoagulation therapy	Iatrogenic, post-procedure	Localized peripheral vision loss	Depends on treatment area	Laser-induced retinal scarring	Ophthalmologic follow-up, vision rehabilitation
Functional/malingering	Variable	Reported tunnel vision without objective findings	Normal fundoscopy and perimetry	Psychological or secondary gain	Verification by formal visual field testing, counseling

Special considerations

Ensure patient safety: remove hazards, provide orientation in home and clinic.
Reassure the patient; vision loss can be anxiety-provoking.
Prepare patient for diagnostic procedures: tonometry, perimetry, ophthalmoscopy.
Encourage use of assistive devices if mobility is affected.

Patient counseling

Explain cause and prognosis of tunnel vision.
Teach techniques to compensate for peripheral vision loss: scanning head movements, guide cane, orientation strategies.
Reinforce safety precautions at home and outdoors.
Discuss treatment options (medications, surgery, vision aids).

Pediatric pointers

Retinitis pigmentosa in children: night blindness typically precedes tunnel vision.
Early recognition allows supportive care and visual rehabilitation.
Monitor for progression of visual field loss and assess for developmental or mobility issues.

References

Biswas J, Krishnakumar S, Ahuja S. Manual of Ocular Pathology. New Delhi, India: Jaypee—Highlights Medical Publishers; 2010.
Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.
Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.
Weinreb RN, Khaw PT. Primary Open-Angle Glaucoma. Lancet. 2004;363:1711–1720.
Hartong DT, Berson EL, Dryja TP. Retinitis pigmentosa. Lancet. 2006;368:1795–1809.