An 86-year-old woman with atrial fibrillation presents with difficulty seeing to the left

The image is consistent with a diagnosis of left homonymous hemianopia.

• 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.

• 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.

• 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.

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.