An 86-year-old woman with atrial fibrillation presents with difficulty seeing to the left
What is your diagnosis?
The diagnosis is...
The image is consistent with a diagnosis of left homonymous hemianopia.
What is the role of the primary care or emergency medicine physician?
- Homonymous hemianopia is caused by lesions of the visual pathways in the brain, and it therefore requires evaluation for underlying etiology.
- All patients require neuroimaging, usually magnetic resonance imaging (MRI).
- Common causes include stroke, traumatic brain injury, and brain tumors.
- Physical examination should focus on a thorough neurologic examination including vision-specific tests such as:
- visual acuity
- confrontation visual fields
- general neurological tests such as assessing for weakness, decreased sensation, or upper motor neuron signs
- Consider driving restrictions by state.
What is the role of the ophthalmologist?
- Perform a comprehensive ophthalmic examination including confrontation testing and visual field testing, to classify and monitor the visual field deficit:
- Central nervous system lesions tend to respect the vertical meridian.
- Visual field testing may aid in determining the location of central nervous system pathology.
- Homonymous hemianopia may be complete (missing whole visual hemifield) or incomplete.
- Incomplete deficits are further categorized: congruous (identical defect in each eye) or incongruous.
- Determine etiology as urgent or nonurgent through neurologic examination and imaging
- Consider consultation with neurology and monitor treatment outcomes for urgent entities.
- Consider visual rehabilitation strategies for homonymous hemianopia.
What is the treatment?
- Treatment options are limited for homonymous hemianopia:
- Focus on utilizing intact visual fields and adapting a patient's environment.
- Discuss current rehabilitation strategies, which include spectacle-mounted prisms, compensatory saccadic training, and visual restoration therapy (see more details here).
- Patients should have close follow-up with their primary care physician to initiate preventative interventions against future episodes:
- Interventions will depend on the cause of the visual pathway lesion in the brain.
Learn more: Ophthalmology resources for medical students
Interactive Case: Sudden Vision Loss
Medical Knowledge Video: Central Causes of Vision Loss
Interactive Figure: The Visual Pathway
Careers in Ophthalmology Video Series: Neuro-Ophthalmology
Additionally, consider watching this video about Management of Acute Vision Loss in the Emergency Department.