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Scotoma

A scotoma is a medical term for a visual field defect characterized by a blind spot or area of partial or complete vision loss surrounded by areas of normal or relatively better vision. Scotomas can be physiological, such as the normal blind spot where the optic nerve exits the retina, or pathological.^[1] This abnormality typically affects one eye but can occur in both, resulting from disruptions in the retina, optic nerve, or visual pathways in the brain, and it may be temporary or permanent depending on the underlying cause.^[2] Scotomas are classified into various types based on their location, appearance, and etiology. Central scotomas involve the central field of vision and often stem from lesions affecting the papillomacular bundle of the optic nerve, leading to impaired fine visual acuity.^[1] Paracentral scotomas occur slightly off-center, within about 10 degrees of the fixation point, while arcuate or cuneate scotomas follow curved patterns along nerve fiber bundles and are commonly associated with glaucoma.^[2]^[1] Scintillating scotomas, marked by shimmering or zigzag patterns, frequently accompany migraine auras and are usually transient.^[2] Other variants include junctional scotomas from damage near the optic chiasm and positive scotomas, where patients perceive visual disturbances like spots, versus negative ones that are only detectable through testing.^[2]^[3] The causes of scotomas are diverse and often indicate underlying ocular or neurological conditions. Common triggers include migraines, glaucoma, macular degeneration, and retinal disorders such as detachment or vascular occlusions.^[2]^[3] Brain-related issues like strokes, tumors, multiple sclerosis, or optic neuritis can also produce scotomas by interrupting visual signal transmission.^[3]^[4] Certain medications, such as hydroxychloroquine (Plaquenil), and systemic diseases like diabetes or hypertension further contribute to their development.^[3] Diagnosis relies on visual field testing, including automated static perimetry, which maps blind spots by presenting flickering lights in a dome-shaped perimeter while the patient fixates on a central point.^[3] These tests quantify the size, shape, and depth of scotomas, aiding in identifying the affected visual pathway.^[1] Treatment addresses the root cause: temporary scotomas from migraines may resolve with rest or medications like triptans, while chronic ones from glaucoma require intraocular pressure-lowering drugs or surgery.^[2] In cases of irreversible vision loss, low-vision aids such as magnifiers or rehabilitation strategies help patients adapt.^[2] Early detection through routine eye exams is crucial, as scotomas can signal progressive conditions threatening overall visual function.^[3]

Overview

Definition

A scotoma is defined as a discrete area of partial or complete loss of vision within the visual field, surrounded by regions of normal or relatively preserved vision.^[5]^[2] This localized visual defect contrasts with generalized vision impairment, as it manifests as an isolated blind spot or patch of diminished acuity rather than widespread blindness.^[6] The term "scotoma" originates from the Greek word skotōma, meaning "darkness" or "dizziness," reflecting its association with obscured sight; it entered English medical usage in the mid-19th century, with early ophthalmological applications around 1875.^[7]^[2] Scotomas arise from dysfunction anywhere along the visual pathway, including the retina, optic nerve, optic chiasm, optic tracts, or visual cortex, leading to either relative (partial) or absolute (complete) vision loss in the affected area.^[8] Unlike the physiological blind spot inherent to normal vision due to the optic disc, pathological scotomas indicate underlying abnormalities.^[8]

Physiological Blind Spot

The physiological blind spot, also known as the optic disc scotoma, arises from the absence of photoreceptor cells at the optic disc, where retinal ganglion cell axons converge to form the optic nerve, resulting in a natural gap in visual perception.^[9] This region, lacking rods and cones, creates a scotoma spanning approximately 5 to 7 degrees of visual angle, with a vertical extent of about 7 degrees and horizontal extent of 5 degrees.^[10] In terms of location, the blind spot is situated on the nasal retina, projecting to the temporal visual field of each eye, centered roughly 15 degrees temporal to the fixation point and 1.5 degrees below the horizontal meridian. On the retina, it measures about 1.5 mm in diameter, corresponding to this angular size due to the eye's focal length.^[10] For the right eye, this places the blind spot approximately 15 degrees to the right of fixation, while for the left eye, it is 15 degrees to the left, ensuring minimal overlap in binocular vision.^[11] The brain compensates for this gap through perceptual completion, a process where surrounding visual information from adjacent retinal areas is used to fill in the missing details, creating a seamless perceptual experience without conscious awareness of the defect. This filling-in occurs rapidly and automatically, often involving neural activity in retinotopic cortical areas that represent the blind spot region, integrating contours and colors from flanking stimuli.^[12] This phenomenon can be demonstrated experimentally using a simple blind spot test: with one eye closed, fixate on a distant point while holding a small dot (e.g., 5 mm diameter) at arm's length about 15 degrees temporal to fixation on a plain background; slowly move the paper closer until the dot disappears, confirming the scotoma's location.^[13] Alternatively, Troxler's fading illustrates completion at the blind spot, where a static pattern viewed steadily in the peripheral field fades due to adaptation, with the brain filling the void from surrounding input after 5-10 seconds of fixation.^[12]

Clinical Aspects

Signs and Symptoms

Patients with a scotoma typically report a localized area of diminished or absent vision within their visual field, often described as a dark patch, blurred spot, or missing segment where visual information is not perceived.^[2]^[14] This blind spot can vary in size and shape, appearing as a "dark hole" in the vision that obstructs normal sight.^[14] Central scotomas, affecting the central visual field, are particularly disruptive and may manifest as an unclear or shadowy area directly in the line of sight, making tasks like reading or recognizing faces challenging.^[2] Associated symptoms can include photopsia, such as flashes of light or floaters, as well as difficulty distinguishing colors or a need for brighter lighting to compensate for reduced visual acuity.^[2] In some cases, patients experience headaches or distorted vision (metamorphopsia), though these features depend on the specific presentation.^[2] For instance, a scintillating scotoma may involve shimmering or wavy patterns shifting between light and dark, often preceding a migraine.^[15] The onset of symptoms can be acute, occurring suddenly and affecting one or both eyes, or gradual, progressing over time and potentially enlarging the affected area.^[2]^[14] Unilateral scotomas impact a single eye, while bilateral ones involve both, and the condition may be temporary or persistent.^[2] Peripheral scotomas are frequently asymptomatic and only noticed when they impinge on central vision, whereas central ones lead to significant functional impairments, such as difficulties with reading, driving, or navigating environments.^[2]

Visual Impact

Central scotomas profoundly limit tasks dependent on high-resolution central vision, such as reading and face recognition. Reading performance declines markedly due to obscured fixation points, resulting in slower speeds, longer fixation durations, and increased regressions that hinder comprehension and oculomotor efficiency.^[16] Face recognition is similarly impaired, as affected individuals struggle to fixate on key features like the eyes, nose, and mouth, forcing reliance on lower-acuity peripheral vision and pseudofoveal loci that reduce accuracy.^[17] In contrast, peripheral scotomas compromise mobility and hazard detection by narrowing the effective visual field, leading to reduced horizontal scanning amplitudes and heightened collision risks during navigation in cluttered or dynamic settings.^[18] Individuals with scotomas often adapt through enhanced eye movement strategies, including frequent saccades to reposition the blind spot and exploit residual vision in spared retinal areas. Saccadic adaptation recalibrates these movements, allowing effective use of peripheral retina even with central defects, as demonstrated in simulations where adaptation occurs comparably to normal conditions by leveraging post-saccadic peripheral feedback.^[19] These functional challenges extend to psychological burdens, fostering frustration, anxiety, and depression; notably, one in four adults with vision loss experiences anxiety or depression, with younger individuals facing nearly five times the risk compared to those without impairment.^[20] Such effects diminish employment prospects by restricting visual task performance and erode independence, often necessitating accommodations or assistance for work and daily activities.^[21] The impact's severity is assessed via visual field extent in degrees, where contraction to 20 degrees or less in the better eye—accounting for scotoma size excluding the physiologic blind spot—meets criteria for statutory blindness, influencing legal and disability determinations.^[22]

Etiology

Ocular Causes

Ocular causes of scotomas primarily involve pathologies affecting the retina or optic nerve, leading to localized visual field defects prior to the optic chiasm. These conditions disrupt the transmission of visual signals from the eye's photoreceptors or nerve fibers, resulting in blind spots that can vary in size, shape, and location depending on the underlying damage.^[23] Retinal disorders are a major contributor to scotomas, often manifesting as central or peripheral defects due to degeneration or vascular changes in the retinal layers. Age-related macular degeneration (AMD), particularly the advanced dry or wet forms, commonly produces central scotomas by damaging the macula, the region responsible for sharp central vision; this leads to a progressive blind spot that impairs reading and face recognition.^[24] Retinal detachment produces a scotoma in the visual field corresponding to the detached area.^[25] Retinitis pigmentosa, an inherited group of disorders, causes peripheral ring scotomas through the gradual loss of rod photoreceptors in the mid-peripheral retina, forming an annular blind area that encroaches inward over time and reduces night vision and side vision.^[26]^[27] Optic nerve pathologies, including glaucomatous and inflammatory conditions, frequently result in arcuate or central scotomas from axonal damage or compression. In glaucoma, elevated intraocular pressure leads to arcuate scotomas that follow the pattern of retinal nerve fiber bundles, creating bow-shaped defects typically 10-20 degrees from fixation and progressing to peripheral vision loss if untreated.^[28] Optic neuritis, often arising from demyelination, produces central or cecocentral scotomas due to acute inflammation of the optic nerve head or sheath, with visual field defects appearing in nearly all cases, approximately 90% or more; while primarily an ocular event, it may signal broader demyelinating processes.^[29]^[30] Other ocular etiologies include vascular and toxic insults. Diabetic retinopathy can generate spotty or irregular scotomas from retinal hemorrhages, microaneurysms, or neovascularization that block light transmission in scattered areas, particularly in proliferative stages. Retinal vascular occlusions, such as central retinal artery occlusion, cause central or altitudinal scotomas.^[31]^[32] Toxic optic neuropathy, such as that induced by methanol poisoning, causes bilateral central scotomas through mitochondrial toxicity to retinal ganglion cells, often presenting with rapid vision loss and dyschromatopsia following exposure. Chronic use of medications such as hydroxychloroquine can lead to paracentral scotomas through retinal toxicity manifesting as bull's eye maculopathy.^[33]^[34]^[35]

Neurological Causes

Neurological causes of scotomas arise from disruptions in the central nervous system pathways involved in visual processing, distinct from primary ocular pathologies. These include vascular events, inflammatory or demyelinating conditions, compressive lesions from tumors, traumatic injuries, and rare functional disorders. Such scotomas often reflect damage to the optic chiasm, tracts, radiations, or visual cortex, leading to characteristic field defects like homonymous hemianopia or bitemporal patterns.^[36] Vascular insults, particularly ischemic strokes affecting the visual cortex, commonly produce homonymous hemianopic scotomas. These defects occur when infarction in the occipital lobe interrupts retinotopic processing, resulting in congruent visual field loss in both eyes contralateral to the lesion. For instance, posterior circulation strokes involving the posterior cerebral artery can cause dense hemianopic scotomas that spare the central macula in some cases, though macular splitting may occur with extensive damage. Embolic strokes often yield wedge-shaped or quadrantanopic scotomas due to the vascular territory of cortical arterioles.^[36]^[37]^[38] Inflammatory and demyelinating diseases, such as multiple sclerosis (MS), frequently manifest with paracentral scotomas due to lesions in the optic nerve or periventricular white matter affecting visual pathways. In MS, these scotomas often accompany optic neuritis, presenting as central or cecocentral defects that may resolve partially with remyelination, though persistent field loss can occur in chronic cases. Migraines, another inflammatory-related process, produce transient scintillating scotomas as part of the aura phase, characterized by shimmering, zigzag patterns expanding from the central visual field and lasting 10-30 minutes before resolving without permanent deficit. These auras stem from cortical spreading depression in the occipital region, mimicking ischemic events but without structural damage.^[39]^[30]^[40]^[41] Tumors and traumatic brain injuries represent compressive or direct disruptive causes of scotomas. Pituitary adenomas, by compressing the optic chiasm, lead to bitemporal scotomas or hemianopia, with larger tumors (>2 cm) more likely to produce significant field defects starting superiorly and progressing inferiorly. Traumatic brain injury (TBI) can induce scotomas through shearing of visual pathways or cortical contusions, resulting in homonymous defects, paracentral scotomas, or even monocular hemianopia in mild cases; blast-related TBI often reveals subtle field deficits on automated perimetry.^[42]^[43]^[44]^[45] Rarely, hysterical or functional scotomas occur without organic neurological pathology, representing non-organic visual loss where patients report field defects inconsistent with anatomical pathways, such as spiral or tubular vision. These are psychogenic in origin, often linked to stress or conversion disorder, and diagnosed by discrepancies in formal testing like inconsistent visual fields or normal electrophysiological responses.^[46]^[47]

Classification

Types of Scotomas

Scotomas are classified based on their location within the visual field and their characteristic patterns, which help in understanding the underlying anatomical involvement. Location-based classifications include central, paracentral, peripheral, arcuate, and hemianopic types, each corresponding to specific regions of visual processing.^[5]^[2] Central scotomas involve the foveal region and fixation point, leading to impaired central vision and reduced visual acuity. Paracentral scotomas occur adjacent to the central area, typically within 10 degrees of fixation, and may appear nasal or temporal to the fixation point. Peripheral scotomas affect the outer regions of the visual field, sparing central vision. Arcuate scotomas follow the arc-like path of retinal nerve fiber bundles, often extending from the blind spot toward the periphery, as seen in conditions affecting nerve fiber layers. Hemianopic scotomas involve loss across an entire half of the visual field, resulting from post-chiasmal lesions.^[5]^[2]^[48] Pattern-based classifications describe the shape and appearance of the defect. Ring or annular scotomas form a circular band of vision loss surrounding preserved central and peripheral areas, such as in advanced glaucoma where arcuate defects merge. Wedge-shaped or sector scotomas present as triangular or pie-slice defects, often linked to localized lesions in structures like the lateral geniculate nucleus. Scintillating scotomas feature shimmering or zigzag edges, typically transient and associated with migraine auras.^[49]^[50]^[51]^[2] Scotomas can also be unilateral, affecting one eye due to local ocular or pre-chiasmal lesions, or bilateral, involving both eyes from systemic conditions or chiasmal/post-chiasmal issues. A notable example is the cecocentral scotoma, which combines central and blind spot involvement and is characteristic of optic neuropathies like toxic or nutritional types.^[2]^[52]^[48]

Absolute and Relative Scotomas

An absolute scotoma refers to a localized area in the visual field where there is a complete absence of light perception, such that no stimuli—not even the brightest lights or colors—can be detected within that region.^[5]^[6]^[53] This total loss of vision in the affected area distinguishes it from normal physiological blind spots, indicating profound dysfunction in the underlying retinal, optic nerve, or cortical structures. In contrast, a relative scotoma involves partial vision loss, where sensitivity is reduced but not entirely eliminated; dimmer or smaller targets may go undetected, while brighter or larger ones remain visible, often manifesting as dimmed vision or color desaturation.^[54]^[6]^[55] Subtypes include those relative to specific colors, such as a scotoma for red targets (red desaturation) where white or other colors may still be perceived, commonly assessed in conditions affecting the optic nerve.^[56]^[57]^[58] Perimetry, a standard visual field testing method, measures and maps the density gradients of these scotomas by presenting stimuli of varying intensity and size; absolute scotomas appear as regions of zero sensitivity (complete blackness on grayscale readouts), while relative scotomas show intermediate shades indicating residual function.^[59]^[60]^[54] Clinically, absolute scotomas signal severe, often irreversible damage to visual pathways, whereas relative scotomas suggest milder impairment with potential for improvement through treatment, such as in inflammatory optic neuropathies.^[1]^[61] For instance, central absolute scotomas are characteristic of advanced age-related macular degeneration.^[61]

Diagnosis

Detection Methods

Confrontation testing serves as a fundamental bedside method for detecting gross visual field defects, including scotomas, by having the examiner and patient face each other at approximately 2 meters. The patient covers one eye while fixating on the examiner's nose, and the examiner presents a finger or wiggling digit from the periphery toward the center of the visual field in each quadrant to identify areas of reduced or absent perception.^[3]^[1] This qualitative technique is quick, requires no specialized equipment, and is particularly useful for screening large-scale scotomas in clinical settings, though it may miss subtle defects.^[1] The Amsler grid provides a simple self-assessment tool for identifying central scotomas, consisting of a square grid of horizontal and vertical lines with a central fixation point. Patients hold the grid at reading distance, cover one eye, and fixate on the center while noting any missing grid lines, distortions, or blank areas that indicate scotomatous regions in the macula.^[62] This test is especially valuable for monitoring conditions affecting the central 10 degrees of the visual field, such as macular degeneration, and can be performed at home for ongoing detection.^[62] Tangent screen perimetry offers a manual approach for detailed mapping of central visual field defects, using a black felt screen marked with concentric circles and radial lines positioned 1 to 2 meters from the patient. Small white targets are moved along radial meridians from the periphery toward fixation to delineate scotoma boundaries within the central 30 degrees of vision.^[11] This method enhances precision over confrontation testing by quantifying defect size and shape at near distances.^[63] Historically, the Bjerrum screen, a variant of the tangent screen developed by Jannik Bjerrum in the early 20th century, was instrumental in identifying arcuate scotomas associated with glaucoma, by systematically plotting defects along nerve fiber bundle paths in the paracentral field.^[59] This technique involved moving test objects across the screen to reveal characteristic arched blind spots originating from the blind spot.^[59] For more precise quantification, advanced automated perimetry tools can supplement these manual methods in clinical practice.^[3]

Clinical Assessment

Clinical assessment of scotomas involves quantitative and objective techniques to precisely map defects, evaluate underlying structures, and differentiate etiologies. Automated perimetry is a cornerstone for detailed characterization, utilizing devices such as the Humphrey Field Analyzer and Octopus perimeter to perform static threshold testing, which maps sensitivity across the visual field by presenting stimuli of varying intensities at predefined locations.^[64]^[59] This approach generates topographic maps of scotomas, identifying absolute or relative defects with high reproducibility and sensitivity to progression. For patients with low vision or unreliable fixation, Goldmann kinetic perimetry employs moving stimuli to delineate the boundaries of scotomas, providing complementary data on peripheral field extent.^[59]^[65] Imaging modalities further refine assessment by visualizing structural correlates. Optical coherence tomography (OCT) offers high-resolution cross-sectional imaging of retinal layers, detecting abnormalities such as thinning or disruptions in the outer retina that correspond to central or paracentral scotomas.^[66]^[67] For suspected neurological origins, magnetic resonance imaging (MRI) identifies lesions in the optic pathways or occipital cortex responsible for homonymous scotomas, with sequences like diffusion-weighted imaging highlighting acute infarcts or demyelination.^[68]^[69] Electrophysiological testing, particularly visual evoked potentials (VEP), assesses the integrity of the visual pathway from retina to cortex. Pattern-reversal VEP measures latency and amplitude of cortical responses to structured stimuli, with delays or attenuations indicating conduction defects that align with scotoma locations.^[70]^[71] Multifocal VEP variants provide topographic data, correlating electrophysiological abnormalities with specific field defects.^[72] Differential diagnosis distinguishes functional from organic scotomas through consistency across repeated tests. In automated perimetry, variability in threshold responses, fixation losses, or false positives exceeding normative thresholds suggests non-organic origins, as organic defects typically show stable patterns.^[73]^[47] Such testing, combined with imaging and electrophysiology, ensures reliable characterization without relying solely on subjective reports. Basic confrontation methods like the Amsler grid may prompt referral but are insufficient for quantitative assessment.^[64]

Management

Treatment Options

Treatment of scotomas primarily targets the underlying etiology, with interventions aimed at halting progression or restoring function where possible. For ocular causes, therapies focus on stabilizing retinal or optic nerve damage to prevent scotoma enlargement or facilitate partial recovery. Neurological treatments address inflammatory, vascular, or compressive mechanisms, while supportive strategies enhance adaptation for persistent visual field defects. Emerging options, particularly for genetic origins, show promise in preclinical and early clinical stages as of 2025. In cases of wet age-related macular degeneration (AMD), which often presents with central scotomas due to choroidal neovascularization, intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections such as ranibizumab, aflibercept, or bevacizumab serve as the first-line therapy. These agents inhibit abnormal vessel growth and leakage, stabilizing vision and reducing scotoma size in many patients after multiple injections, typically administered monthly initially. For diabetic retinopathy, where scotomas arise from macular edema or ischemic areas, pan-retinal photocoagulation laser therapy remains a standard intervention, particularly for proliferative disease, by sealing leaking vessels and reducing neovascularization risk, thereby preserving peripheral fields. In glaucoma, intraocular pressure (IOP)-lowering eye drops, including prostaglandin analogs like latanoprost or beta-blockers such as timolol, are prescribed to slow optic nerve damage and limit scotoma expansion, with target IOP reductions of 20-30% often achieving field stabilization. Neurological scotomas from optic neuritis, commonly associated with multiple sclerosis, respond to high-dose intravenous corticosteroids like methylprednisolone (1 g/day for 3-5 days), which accelerate visual recovery and may lessen residual central scotomas, though long-term outcomes vary. For migraine-related scintillating scotomas, prophylactic beta-blockers such as propranolol (40-240 mg/day) reduce attack frequency by up to 50% in responsive patients, mitigating recurrent visual auras. When scotomas result from brain tumors compressing the optic pathways, surgical resection—often via craniotomy or endoscopic approaches—relieves pressure, with visual field improvements noted in 60-80% of cases depending on preoperative duration. Supportive low-vision rehabilitation is essential for irreversible scotomas, employing optical aids like handheld magnifiers (2-10x power) to enlarge images in the intact field and training in scanning techniques to compensate for defects, such as systematic eye movements to locate objects. These multidisciplinary programs, involving occupational therapists, improve daily functioning and quality of life by optimizing residual vision. As of 2025, gene therapy trials for inherited retinal dystrophies like retinitis pigmentosa, which cause progressive peripheral scotomas, utilize adeno-associated viral vectors to deliver functional genes (e.g., RPE65), showing modest visual field preservation in phase II/III studies with sustained effects up to 4 years post-injection. Prognosis variability underscores the need for early intervention tailored to the cause.

Prognosis and Complications

The prognosis of scotoma varies significantly depending on its underlying cause, with some forms offering high potential for recovery and others leading to progressive vision loss. In cases associated with migraines, scotomas are typically temporary and resolve spontaneously within 20-60 minutes as the aura phase concludes, resulting in full visual recovery without long-term sequelae. For scotomas stemming from optic neuritis, the outlook is generally favorable, with approximately 90-94% of patients achieving visual acuity of 20/40 or better within 6-12 months, though residual central or paracentral defects may persist in a minority of cases. In contrast, scotomas due to age-related macular degeneration (AMD) are often permanent and progressive; in dry AMD, central scotomas from geographic atrophy may enlarge slowly over years, while wet AMD can cause rapid deterioration but responds better to interventions, potentially stabilizing vision in many patients. Scotomas in glaucoma, particularly paracentral or arcuate types, tend to progress inexorably without intraocular pressure management, leading to irreversible field loss and potential blindness in untreated advanced cases over 5-10 years. Complications arising from scotomas primarily stem from impaired visual field awareness and central vision deficits, increasing the risk of falls and injuries due to mobility challenges and environmental navigation difficulties. Social isolation frequently occurs as individuals withdraw from activities requiring precise vision, such as reading or driving, exacerbating emotional distress. Secondary depression is a common sequela, affecting up to 25% of those with significant visual field loss, often compounded by reduced quality of life and functional independence. Several factors influence scotoma prognosis, including early detection, which enables timely intervention to halt progression in treatable causes like optic neuritis or glaucoma. Patient age plays a critical role, with older individuals facing poorer outcomes due to slower recovery and higher comorbidity burden in conditions such as AMD. Comorbidities, particularly diabetes, worsen vascular-related scotomas by accelerating retinal damage and reducing treatment efficacy. Scotomas contributing to visual impairment are evaluated for disability benefits through standardized assessments of field loss extent. In the United States, the Social Security Administration measures scotoma impact via automated perimetry, qualifying individuals for benefits if central visual field diameter is 20 degrees or less in the better eye, or if combined acuity and field deficits meet listing criteria for statutory blindness. The Department of Veterans Affairs assigns ratings such as 10% per eye for scotomas affecting at least one-quarter of the visual field within 30 degrees of fixation, influencing compensation for service-related vision loss.

Non-Medical Applications

Terminology in Psychology

In psychology, a scotoma refers to a metaphorical blind spot in perception and cognition, representing areas of emotional or cognitive reality that an individual ignores or fails to acknowledge, often as a defense mechanism against discomfort or dissonance. This concept extends the neurological term beyond literal vision loss to describe gaps in awareness, such as denial of personal flaws or repressed experiences, which can hinder self-understanding and adaptive behavior.^[74]^[75] The term entered psychological discourse through Freudian psychoanalysis, where French psychiatrist René Laforgue introduced "scotomization" in a 1925 letter to Sigmund Freud, framing it as an infantile wish to deny external reality and maintain psychic equilibrium. Laforgue's idea influenced later analysts, including Melanie Klein, who in 1935 elaborated on scotomisation as a psychological blind spot arising from early defensive processes, akin to splitting in the face of anxiety. In modern cognitive behavioral therapy (CBT), the concept persists as a tool to identify and challenge cognitive blind spots, such as distorted self-perceptions that perpetuate maladaptive patterns, emphasizing awareness to foster behavioral change.^[76]^[77] Examples of psychological scotomas include emotional denial in mental health contexts, where individuals with trauma histories may overlook interpersonal cues signaling support, perpetuating isolation. In psychopathy, it manifests as a profound unawareness of personal responsibility, leading to repeated interpersonal conflicts without remorse or insight. This metaphorical usage draws an analogy to neurological hemispatial neglect, where patients ignore one side of space due to brain injury, but psychological scotomas involve no organic pathology—solely learned or defensive inattention to internal or social realities.^[78]^[79]

Broader Conceptual Uses

In philosophy, the term "scotoma" has been employed metaphorically to describe gaps in perception and the limits of consciousness, particularly in Lacanian theory where it signifies a blind spot in the visual field analogous to the elusive "gaze" that disrupts subjective vision and reveals the Real as an unrepresentable void beyond symbolic order.^[80] This usage underscores how perceptual absences structure human encounter with the world, echoing broader phenomenological concerns with embodiment and the invisible aspects of experience.^[81] Sociologically, "scotoma" extends to "cultural scotoma," denoting collective patterns of inattention or denial that obscure societal issues such as inequality and systemic injustice, as articulated in analyses of 20th-century American reform discourses where individualism fosters depoliticized activism focused on personal rather than structural problems.^[82] Neurologist Oliver Sacks further popularized this in his 2017 essay "Scotoma: Forgetting and Neglect in Science," applying it to historical oversights in scientific recognition, such as the delayed acknowledgment of Darwin's precursors, framing such neglect as a "social scotoma" rooted in cultural biases that perpetuate inequities in knowledge production.^[83] This metaphorical shift highlights how shared perceptual gaps reinforce power dynamics, akin to blind spots in collective memory that hinder social progress. In modern management literature, "scotoma" metaphorically represents overlooked operational risks or opportunities, such as "mental scotomas" in business processes where leaders fail to detect inefficiencies due to ingrained assumptions, leading to failures in visibility and decision-making.^[84] Similarly, in systems thinking, it denotes unconscious biases from conceptual metaphors that obscure complex interactions, urging practitioners to scrutinize language and worldviews to reveal hidden patterns and avoid marginalizing alternative perspectives.^[85] For instance, "innovation scotomas" describe managerial blind spots to disruptive ideas, as explored in organizational theory where cultural norms suppress novel solutions, emphasizing the need for deliberate reframing to foster creativity. The metaphorical evolution of "scotoma" traces from its medical origins in the early 20th century—initially denoting literal visual defects—to broader psychological and social applications by mid-century, gaining traction through Sacks' 1984 autobiographical work A Leg to Stand On, where it illustrates personal sensory denial, and extending into 21st-century self-help paradigms.^[83] In personal development, Tony Robbins adopted it in his 1986 book Unlimited Power to signify mental blind spots blocking success, such as limiting beliefs that prevent recognizing opportunities, advocating mindset shifts to "fill in" these gaps for empowerment and goal attainment.^[86] This progression reflects a transition from clinical descriptor to a versatile tool for critiquing perceptual limitations across disciplines.

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This review aims to discuss retinal diseases that may masquerade as neurological causes of vision loss and highlights modern ophthalmic ancillary testing ...
[24]
Age-Related Macular Degeneration - EyeWiki
Age-related macular degeneration (AMD) is an acquired degeneration of the retina that causes significant central visual impairment.<|separator|>
[25]
Retinitis Pigmentosa - EyeWiki
Jun 1, 2025 · ... ring scotoma in the midperiphery of the visual field. This usually starts as a group of isolated scotomas around 20 degrees from fixation ...Disease Entity · Diagnosis · Diagnostic Procedures · Differential Diagnosis
[26]
Nonsyndromic Retinitis Pigmentosa Overview - GeneReviews - NCBI
Apr 6, 2023 · ... scotomas (blind spots). In early RP, a ring scotoma often is present in the mid-periphery of the visual field approximately 20-25 degrees ...Clinical Characteristics of... · Causes of Nonsyndromic... · Genetic Risk Assessment
[27]
Arcuate scotoma - American Academy of Ophthalmology
An arcuate scotoma occurs in the area 10 degrees–20 degrees from fixation. Glaucomatous damage to a nerve fiber bundle containing axons from both the ...
[28]
Demyelinating Optic Neuritis - EyeWiki
Jun 2, 2025 · Immune-mediated inflammatory demyelination of the optic nerve. The ... Any nerve fiber layer or central scotoma on Amsler grid and/or ...Disease Entity · Diagnosis · Diagnostic Procedures · Differential diagnosis
[29]
Optic Neuritis - StatPearls - NCBI Bookshelf - NIH
Jan 20, 2025 · Visual field defects: Central scotomas (blind spots) are frequently identified on visual field testing. These defects correspond to the area of ...Optic Neuritis · Toxicokinetics · Evaluation
[30]
Diabetes-Related Retinopathy: Symptoms, Stages & Treatment
Diabetes-related retinopathy is retinal disease that happens because of diabetes ... Blind spots (scotomas); Visual field defects; Low vision and vision loss ...Missing: spotty | Show results with:spotty
[31]
Toxic Optic Neuropathy - EyeWiki
Apr 23, 2025 · ... Toxic optic neuropathy. Indian J Ophthalmol 59: 137-141. ↑ Walsh F, Hoyt W (2005). Neurotoxic substances: Methyl Alcohol. In: Rizo M ...Disease Entity · Pathophysiology · Diagnosis · Signs
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Methanol-induced optic neuropathy: a still-present problem - PMC
Massive outbreaks of toxic optic neuropathy (TON) associated with acute or chronic methanol poisoning occurred in the last century in the 1950s in the US ( ...
[33]
Eyes and stroke: the visual aspects of cerebrovascular disease - PMC
Jul 6, 2017 · Strokes have a high likelihood of involving vision in some way. Vision loss can be the most disabling residual effect after a cerebral infarction.
[34]
A Prospective Profile of Visual Field Loss following Stroke
Visual field loss following stroke has largely been attributed to cortical strokes in which the visual pathway is damaged.
[35]
Patterns of Cortical Visual Field Defects From Embolic Stroke ...
The scotoma can extend quite far, beyond the horizontal meridian, but it will not reach all the way to the other vertical meridian. The latter is protected ...Cortical Arterioles And... · Anastomotic Surface... · Cortical Vascular...
[36]
Optic Neuritis as First Clinical Manifestations the Multiple Sclerosis
Analyzing disturbances in the computerised visual field: centrocecal and paracentral scotoma and diffuse sensitivity, we find most frequent disturbances in the ...
[37]
Migraine aura - Mayo Clinic
Auras are sometimes accompanied by a partial loss of vision referred to as a scotoma. Auras commonly last 10 to 30 minutes. A sensory aura is also common ...
[38]
Significance of scintillating scotoma of late onset - PubMed
Scintillating hemianopic scotomas are usually caused either by migraine or, more rarely, vertebral-basilar insufficiency.
[39]
Neuroanatomy, Bitemporal Hemianopsia - StatPearls - NCBI - NIH
This condition is a medical emergency called pituitary apoplexy. The patient will present with acute onset headache, ophthalmoplegia, and visual field defects ...
[40]
The Influence of Pituitary Adenoma Size on Vision and Visual ...
Results from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual ...
[41]
An insight into the vision impairment following Traumatic Brain Injury
Clinical studies suggest that TBI-patients have been suffering from various vision-related issues including photophobia, double vision, blurred vision, loss of ...
[42]
Automated Perimetry and Visual Dysfunction in Blast ... - PubMed
Reliable automated perimetry can be accomplished in most patients with TBI from combat blast exposure and reveals high rates of visual field deficits.
[43]
Nonorganic Vision Loss - StatPearls - NCBI Bookshelf - NIH
Jan 11, 2024 · Nonorganic vision loss (NOVL), also known as functional, psychogenic, or hysterical vision loss, is a unique subset of visual impairment.<|control11|><|separator|>
[44]
Functional Visual Loss - PMC - PubMed Central - NIH
Patients with evidence of nonorganic visual dysfunction are typically described as “functional” in an attempt to avoid having to distinguish between those cases ...
[45]
Patterns of visual field loss in optic neuropathies
A, Cecocentral scotoma (left; arrow); paracentral scotoma (right; arrow). B, Central scotoma (arrow). C, Arcuate scotoma (arrow). D, Broad arcuate (altitudinal) ...
[46]
Open Angle Glaucoma - StatPearls - NCBI Bookshelf
Open-angle glaucoma (OAG) is a chronic, progressive, and irreversible multifactorial optic neuropathy characterized by an open angle of the anterior chamber.
[47]
Scotoma - an overview | ScienceDirect Topics
Central scotomas frequently result from age-related macular degeneration, a continually growing cause of vision loss. People with central scotomas usually have ...<|separator|>
[48]
Use of blue-on-yellow perimetry for detection of sectoranopia | Eye
Mar 8, 2004 · A lesion of the lateral geniculate body can produce a wedge-shaped visual field defect, which is called sectoranopia. The territory of the ...
[49]
Differential diagnosis of visual impairment | STROKE MANUAL
Feb 26, 2024 · unilateral (monocular) disorder is typically caused by a lesion in the retina or optic nerve (prechiasmatic lesion) · binocular defect may occur ...<|control11|><|separator|>
[50]
Understanding Visual Field Defects - Ento Key
Jan 2, 2019 · A scotoma is absolute if the patient cannot see the brightest possible stimulus (of the testing device), or may be relative if some stimuli are ...Optics And Media · Retina · Nerve Fiber Layer/optic Disc
[51]
Visual Fields: Examination and Interpretation - Ophthalmology Review
On the surface, this may seem fairly simple; on a grayscale readout, absolute scotomas tend to be completely black, while relative scotomas are varying shades ...
[52]
Normal Visual Field - Aurosiksha
It is located approximately 15° temporal to the fixation point and about 1.5° below the horizontal meridian. The normal measurement of the blind spot is ...
[53]
Neuro-ophthalmology 1 - AL-Salem Eye Clinic
Nov 22, 2018 · In visual field areas where finger-counting vision has been established look for red desaturation using a red target such as a 4 mm hat pin (a ...Pupils · Investigations · Computed Tomography (ct)
[54]
Optic neuritis - Symptoms, Causes, Images, and Treatment Options
color desaturation/loss of color vision common. Symptoms often described as color of objects not as bright as before.
[55]
Dysthyroid Optic Neuropathy - EyeWiki
Jul 7, 2025 · Color desaturation- Red. In patients with previously normal color vision, asymmetric optic nerve neuropathy may present as color desaturation ...<|separator|>
[56]
Humphrey Visual Field - StatPearls - NCBI Bookshelf - NIH
Jan 20, 2025 · '[6] A "scotoma" refers to a localized area of vision loss within the visual field, essentially a "blind spot." In contrast, a "field defect" is ...
[57]
[PDF] Conventional Perimetry
Defects that retain some degree of differential light sensitivity and do not meet the above descriptions are classified as relative scotomas. It should be ...
[58]
Functional and cortical adaptations to central vision loss - PMC
Retinal damage, either from dry or wet AMD, often results in scotomata (singular: scotoma). Scotoma is an area of reduced light sensitivity on the retina.
[59]
Amsler Grid - StatPearls - NCBI Bookshelf
Aug 25, 2023 · The Amsler Grid is a square-shaped grid used to detect or monitor metamorphopsia or scotoma involving the central visual field in various disorders of the ...
[60]
Visual Field Tests: A Narrative Review of Different Perimetric Methods
Apr 23, 2024 · The tangent screen is more sensitive in delineating the borders of scotomas and is more reproducible than Amsler's grid [130]. The placement of ...<|control11|><|separator|>
[61]
Standard Automated Perimetry - EyeWiki
Each eye has a physiological blind spot at the optic nerve head, where the absence of photoreceptors produces an absolute scotoma roughly 10-15º temporal to the ...Missing: relative | Show results with:relative
[62]
(PDF) Comparative evaluation of Octopus semi-automated kinetic ...
Purpose: The aim of this study was to compare the performance of Octopus 900(OVF) kinetic module with Goldmann perimeter (GVF) and Humphrey 750i (HVF) ...
[63]
Optical Coherence Tomography Findings in the Junctional Scotoma ...
Mar 1, 2021 · The visual acuity was normal and there was a right relative afferent pupillary defect. Formal visual field testing revealed a junctional scotoma ...
[64]
Junctional Scotoma and Junctional Scotoma of Traquair - EyeWiki
Jul 28, 2025 · Junctional scotoma and the junctional scotoma of Traquair are visual field defects that arise from damage to the junction of the optic nerve ...<|separator|>
[65]
Homonymous Hemianopsia - StatPearls - NCBI Bookshelf - NIH
Mar 1, 2024 · Homonymous hemianopsia (HH), or hemianopia, is a visual field deficit affecting corresponding halves of both eyes, often resulting from cerebrovascular injury ...
[66]
Understanding Visual Disorders through Correlation of Clinical and ...
Jan 25, 2024 · Acute left occipital lobe infarction in an 81-year-old man with a right homonymous scotoma. (A) Diffusion-weighted MR image shows a ...
[67]
Visual Evoked Potential/ Response (VEP/VER) - EyeWiki
Sep 27, 2025 · Visual Evoked Potential/Response (VEP/VER) measures the electrical signal generated at the visual cortex in response to visual stimulation.
[68]
Visual Evoked Potential - StatPearls - NCBI Bookshelf
VEPs have been used as an alternative method to assess visual acuity in non-verbal infants and adults with low intellectual abilities or potential malingerers ...
[69]
Significance of Visual Evoked Potentials in the Assessment of Visual ...
Dec 6, 2012 · Visual evoked potentials is an important visual electrophysiological tool which has been used for the evaluation of visual field defects in ...<|control11|><|separator|>
[70]
Conversion Disorder in Neuro-Ophthalmology - EyeWiki
Sep 18, 2025 · A funnel field implies an organic etiology as does the presence of bitemporal or homonymous hemianopsia or central/cecocentral scotomas (which ...
[71]
scotoma - APA Dictionary of Psychology
Apr 19, 2018 · n. an area of partial or complete loss of vision in the visual field. Vision may be depressed (relative scotoma), altered (scintillating scotoma) ...
[72]
Scotoma: Psychology Definition, History & Examples
A scotoma, in psychology, refers to a blind spot or area of understanding that is either undeveloped or ignored by an individual.
[73]
https://eyewiki.org/Conversion_Disorder_in_Neuro-Ophthalmology
[74]
(PDF) Scotoma: The Journey into the Dark - Academia.edu
Melanie Klein's concept of scotomisation ... A `scotoma' is a blind spot, a dark spot, an opacity, an obscuration of part of the visual field. Here is ...
[75]
Psychopathy: Insights for General Practice | Psychiatric Times
Oct 30, 2020 · ... psychological scotoma for personal responsibility. Psychopathic personality traits may also present adaptively in one domain of life, such ...
[76]
Sign-Tracking and Drug Addiction - University of Michigan
A psychological scotoma is a mental activity in which one locks on to one idea and excludes all others. For example, the idea that I am in control of my drug- ...
[77]
[PDF] The Imaginary and Symbolic of Jacques Lacan - DOCS@RWU
One goal in Lacan's concept of the gaze, the real in perception, a gap or sco- toma in perception which is the equivalent of a gap or scotoma in discursive.<|separator|>
[78]
https://www.psychiatrictimes.com/view/psychopathy-insights-general-practice
[79]
Close to Home, One at a Time, Not in My Backyard: Individualism ...
Jul 6, 2019 · 1. Close to Home: A Case of Cultural Scotoma. 3Thus, when in her study Avoiding Politics Nina Eliasoph explored the motivations and strategies ...
[80]
The scotomas as a metaphor in the work of Oliver Sacks
In the first case, he used it to define the sensorial loss of his leg after an accident, which could be interpreted as a «mental scotoma». In the second case, ...
[81]
3 ways to maximize business process visibility
Jan 18, 2023 · Then you've experienced a mental scotoma or blind spot. Drawing its name from a medical condition that involves literal loss of vision, we ...Missing: metaphor | Show results with:metaphor
[82]
Systems Thinkers: Check Your Scotomas and Watch Your Language!
Aug 12, 2019 · 1 A scotoma is a blind spot in what is normal vision. A person with a scotoma is not aware of the scotoma. Since readers might not be familiar ...
[83]
Right Under Our Nose | Leader's Edge Magazine
Oct 27, 2017 · In his book Unlimited Power, Tony Robbins calls this type of event a mental scotoma, which he defines as a mental blind spot. According to ...