Sometimes when a patient tells his ophthalmologist that he "can't see," what he really means is "I can see, but I can no longer read or write." In a minority of Alzheimer's patients the disease shows up first as problems with vision rather than memory or other cognitive functions. But diagnosis can be difficult because standard eye exams are often inconclusive for these patients.

Neuro-ophthalmologists Pierre-Francois Kaeser, MD, and Francois-Xavier Borruat, MD, Jules Gonin Eye Hospital, Switzerland, examined and followed 10 patients with unexplained vision loss who were ultimately diagnosed with the visual variant of Alzheimer's disease (VVAD). Their study -- presented at the 2009 Joint Meeting of the American Academy of Ophthalmology and the Pan-American Association of Ophthalmology (PAAO) -- describes clinical clues that may improve ophthalmologists' ability to detect VVAD and refer patients for further tests. When patients receive neurological assessment, treatment and family counseling early in the disease, outcomes may be better for all concerned.

VVAD patients differ from typical Alzheimer's patients in a number of ways. At the time they report visual problems, many are younger than those for whom memory loss is the tell-tale sign. In Dr. Kaeser's study the median patient age was 65, and only 3 of 10 reported memory loss. In comprehensive neuro-ophthalmic exams even though most patients' visual acuity was adequate, all but one had difficulty with reading, 8 of 10 with writing, and 6 of 10 with basic calculations. The visual field was altered in 8 of 10 patients.

All had trouble identifying colored numbers despite being able to name colors correctly, and, importantly, 8 of 10 patients had difficulty recognizing and interpreting components of a complex image (simultagnosia). This is an early indicator of the brain damage that prevents later-stage Alzheimer's patients from recognizing people they know and navigating familiar surroundings. MRI and PET scans revealed neurological changes consistent with VVAD in all study patients. Though VVAD patients' first symptoms are visual, Alzheimer's memory and personality impairments eventually occur in most.

"Ophthalmologists should be aware of the possibility of VVAD in patients with unexplained vision problems, particularly difficulty with reading," said Dr. Kaeser. "Suspect VVAD when patient tests well for visual acuity but has vision complaints that are unusual or severe for late middle age. Refer him for neurological evaluation."