Neuro-ophthalmology: part 1, visual fields david. kinshuck@goodhope Neuro-ophthalmology: part 1, visual fields david.kinshuck@goodhope.nhs.uk Visual field abnormalities…primarily those related to neuro-ophthalmic problems Case Field defect in relation to anatomical location Importance of the history and examination Quiz 08/12/2018

As you listen she tells you the sight is dim in left eye. case A 43y woman complains of a mild headache (left forehead). The headache has been present 2 months, and is not getting better. As you listen she tells you the sight is dim in left eye. Examination confirms red colours in the left eye are not as bright as when seen with the right eye. Further examination shows a pale optic disk and afferent pupillary defect, and visual field defect, but even without these findings a CT scan is needed. CT scan details: 08/12/2018

case 08/12/2018

Recall …visual pathway 08/12/2018

Recall …disease of the eye itself causes various visual symptoms 08/12/2018

Recall …disease of the eye itself causes various visual symptoms Retinal vascular occlusion cataract Macular degeneration glaucoma Refractive error Retinitis pigmentosa or advanced glaucoma 08/12/2018

Optic nerve 08/12/2018

Pain behind eye with eye movements + visual symptoms Optic nerve No symptoms Loss of colour vision Central scotoma (or greater) Pain behind eye with eye movements + visual symptoms Headache and visual symptoms 08/12/2018

Pituitary (chiasmal) area 08/12/2018

Pituitary (chiasmal) area right left 08/12/2018

Retrochisamal 08/12/2018

Smaller lesions…specificfeatures…this is temporal lobe Retrochisamal Smaller lesions…specificfeatures…this is temporal lobe Large lesion anywhere 08/12/2018

Visual symptoms mini-quiz old patient Central vision reduced optic nerve Central vision reduced ARMD Young patient Superior retinal vein occlusion Loss of colour vision…optic nerve unilateral Tunnel vision…young patient…RP This field both eyes…CVA/SOL Temporal lobe This field both eyes…CVA/SOL 08/12/2018

Questions 08/12/2018

The history can give you a BIG clue Summary The history can give you a BIG clue CT/MRI helpful … but experts will locate lesion without Horizontal border to defects….eye Vertical…..retro-chiasm Early disease…few if any symptoms Small pituitary tumours…no field defect (microadenomas) Key symptoms can be very localising..eg loss of colour vision in one eye, gradual increase in headache over 2 months, 08/12/2018