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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 54-56

The remaining quarter of a pie: Concurrence of two neuro-ophthalmic entities in a patient

Department of Ophthalmology, J.J.M. Medical College, Davanagere, Karnataka, India

Date of Submission01-Sep-2021
Date of Decision09-Jan-2022
Date of Acceptance10-Jan-2022
Date of Web Publication05-Oct-2022

Correspondence Address:
Dr. Gaargi Shashidhar
Department of Ophthalmology, J.J.M. Medical College, Davanagere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jocr.jocr_26_21

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Concurrence of two different neuro-ophthalmic entities in a single patient is rare. The second disease entity may get incidentally detected when the patient is evaluated for one pathology. Such coincidences may be seen in patients having systemic diseases with microvascular complications, such as diabetes mellitus and hypertension. Herein, we report a case of a 62-year-old female patient who was detected to have bilateral inferior altitudinal hemianopia with right homonymous hemianopia as a result of bilateral anterior ischemic optic neuropathy with left occipital lobe infarct.

Keywords: Bilateral Inferior altitudinal hemianopia, Homonymous hemianopia, Occipital lobe infarct

How to cite this article:
Maiya AS, Shashidhar G. The remaining quarter of a pie: Concurrence of two neuro-ophthalmic entities in a patient. J Ophthalmol Clin Res 2022;2:54-6

How to cite this URL:
Maiya AS, Shashidhar G. The remaining quarter of a pie: Concurrence of two neuro-ophthalmic entities in a patient. J Ophthalmol Clin Res [serial online] 2022 [cited 2023 Nov 29];2:54-6. Available from: http://www.jocr.in/text.asp?2022/2/1/54/357891

  Introduction Top

Visual pathway lesions produce typical visual field defects, which help in localizing the site of the lesion, with reasonable accuracy.

While an altitudinal visual field defect is seen in conditions causing retinal nerve fiber layer defects, an inferior altitudinal scotoma is the most common field defect in nonarteritic anterior ischaemic optic neuropathy (NAION).[1] Homonymous hemianopia, on the other hand, is indicative of lesions involving the retrochiasmal visual pathway.[2]

We report a case with a combination of altitudinal scotoma with homonymous hemianopia caused by lesions in the prechiasmal and retrochiasmal visual pathway.

  Case Report Top

A 62-year-old female presented with progressive diminution of vision in both eyes and difficulty in seeing objects in the lower visual field of 6-month duration. She did not have any systemic comorbidities and her systemic examination was also within normal limits. Her younger sibling was a known case of primary angle closure glaucoma, on treatment.

Examination revealed a best corrected visual acuity of 6/12 in the right eye and 6/24 in the left eye. Slit-lamp examination of both eyes revealed shallow peripheral anterior chamber depth (Van Herrick Grade 2) with immature cataract.

Fundus evaluation showed a normal sized optic disc with a significant sectoral pallor of the superior neuroretinal rim in both eyes, a cup-disc-ratio of 0.4:1 in right eye and 0.3:1 in left eye. Macula was normal in both eyes [Figure 1].
Figure 1: Fundus photograph of both eyes showing pallor of superior neuroretinal rim

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Her intraocular pressure by goldmann applanation tonometry was 16 and 18 mmHg in right and left eyes, respectively. Gonioscopy by Volk 4 mirror indirect gonioscope detected Irido-Trabecular Contact with Shaeffer Grade 1–2 in all quadrants of both eyes. She was also detected to have a red-green type of color vision defect and 40% contrast sensitivity (by Pelli Robson Chart) in both eyes.

Standard Automated Perimetry (HFA; Central 30-2) showed bilateral inferior altitudinal hemianopia with a dense right homonymous hemianopia with sparing of one quadrant in each eye (Superonasal quadrant in Right Eye and Superotemporal quadrant in Left Eye) [Figure 2] and [Figure 3].
Figure 2: Visual fields of the right eye showing loss of inferior and temporal fields with sparing of superonasal field

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Figure 3: Visual fields of left eye showing loss of inferior and nasal fields with sparing of superotemporal field

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Her complete blood counts, blood sugar levels, blood pressure, and electrocardiogram were within normal limits, with a slightly deranged serum lipid profile.

Magnetic resonance imaging (MRI) and magnetic resonance (MR) angiogram showed features of chronic infarct in the left occipital lobe in the left posterior cerebral artery territory. MR venogram study was found to be normal [Figure 4] and [Figure 5]. The patient had no significant history of risk factors for cerebral infarct. The exact cause of the infarct could not be determined. After consulting a neurophysician, she was started on oral aspirin 150 mg with atorvastatin 20 mg.
Figure 4: Magnetic resonance imaging brain showing regional loss of neuroparenchyma with gliosis and encephalomalacia (T1/FLAIR hypointensities – a and b; T2 hyperintensities – c and d) in the left occipital lobe suggestive of chronic infarct in left posterior cerebral artery

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Figure 5: Diffusion-weighted images of magnetic resonance imaging brain showing chronic infarct in left posterior cerebral artery territory

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The patient underwent prophylactic Nd: YAG laser peripheral iridotomy in both eyes, followed by cataract surgery of the left eye 6 months later.

  Discussion Top

An inferior altitudinal visual field defect is almost invariably described as the classic field defect in NAION.[1] The pathophysiology of NAION is controversial. It is presumed to result from a circulatory insufficiency, or infarct, within the retrolaminar portion of the optic nerve head that is supplied by the short posterior ciliary arteries.[3]

Visual field loss following stroke has largely been attributed to cortical strokes involving occipital, temporal, and parietal lobes plus middle and posterior cerebral artery infarcts in which the visual pathway is damaged. The most common type of visual field loss was found to be complete and partial homonymous hemianopia.[4],[5] Embolism is the most common cause of posterior cerebral artery ischemia and occipital lobe infarction, including cardiac and local artery to artery sources.[6]

Hence, the use of antiplatelet medications along with statins may help in prevention of recurrences of the above conditions.

Our patient was detected to have a combination of bilateral NAION and left occipital lobe infarction.

Findings in favor of NAION were a sectoral pallor of the superior neuro-retinal rim, defective color vision, reduced contrast sensitivity, and inferior altitudinal hemianopia in both eyes. The right homonymous hemianopia corresponded with the MRI features of left occipital lobe infarct.

  Conclusion Top

To our knowledge, this is the first report of such a case in literature. A systematic and comprehensive ophthalmic and systemic evaluation will help the clinician detect concurrent pathologies whose signs may not be readily evident on clinical examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hayreh SS, Zimmerman B. Visual field abnormalities in nonarteritic anterior ischemic optic neuropathy: Their pattern and prevalence at initial examination. Arch Ophthalmol 2005;123:1554-62.  Back to cited text no. 1
Zhang X, Kedar S, Lynn MJ, Newman NJ, Biousse V. Homonymous hemianopia in stroke. J Neuroophthalmol 2006;26:180-3.  Back to cited text no. 2
Available from: https://eyewiki.aao.org/Non-Arteritic_Anterior_Ischemic_Optic_Neuropathy_(NAION). [Last accessed on 2021 May 04].  Back to cited text no. 3
Rowe FJ, Wright D, Brand D, Jackson C, Harrison S, Maan T, et al. A prospective profile of visual field loss following stroke: Prevalence, type, rehabilitation, and outcome. Biomed Res Int 2013;2013:719096.  Back to cited text no. 4
Rowe F, Brand D, Jackson CA, Price A, Walker L, Harrison S, et al. Visual impairment following stroke: Do stroke patients require vision assessment? Age Ageing 2009;38:188-93.  Back to cited text no. 5
Gilhotra JS, Mitchell P, Healey PR, Cumming RG, Currie J. Homonymous visual field defects and stroke in an older population. Stroke 2002;33:2417-20.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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