Diagnostic Strategies in the Management of Unexplained Visual Loss

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Abstract
In the investigation of visual loss from anterior visual pathway disease, it is imperative to differentiate the infrequent compressive from the much more common noncompressive lesions. To determine how relatively low-cost, risk-free, but error-prone visual field examination (VF) and high-cost, risk-prone, but accurate CT Scan (CT) and cerebral angiography (Angio) can be cost-effectively utilized to solve this diagnostic problem, the authors have developed a decision making model for the analysis of three management strategies. The visual field examination precedes and determines the use of neuroradiologic studies in Strategy A (VF-CT-Angio), whereas it follows the neuroradiologic studies in Strategies B (CT-VF-Angio) and C (CT-Angio-VF). The visual field-determined strategy (A) proved most cost-effective, based upon an estimated 6% or lower relative prevalence of chiasmal compressive lesions, a negligible risk in delaying their diagnosis, and a sensitive method of visual field examination. At a visual field sensitivity to chiasmal defects of 84% and a specificity of 88%, Strategy A annually saves $4 million over Strategy B and $27 million over Strategy C. At lower levels of perimetric accuracy, Strategy B is the most cost-effective approach. Strategy C is never cost-effective.