Crossed-Quadrant Homonymous Hemianopsia

Home , Hemianopsia, Homonymous hemianopsia

John A. Dyer, M.B.B.S., Lawrence W. Hirst, M.D., Kevin Vandeleur, (Snr) M.B.B.S., Terence Carey, M.B.B.S., and Peter R. Mann M.B.B.S.

This case report illustrates the clinicopathological corre CASE REPORT lation between the anatomic defect of bilateral occipital lobe infarction with crossed-quadrant homonymous hemianopsia that resulted from a cervical spine injury. A 30-year-old, right-handed man suffered a frac Routine ophthalmological and neuroradiological inves ture-dislocation of his fifth cervical vertebra after tigations were undertaken, including magnetic reso hitting a log while diving into a shallow pool in nance imaging scanning, that demonstrate some impor 1960. This resulted in transient quadriplegia and tant characteristics of this rare field defect. transient blindness for an undisclosed period of Key Words: Hemianopsia-Perimetry-Computered to mography-Magnetic resonance imaging-Occipital time. He made a remarkable recovery of vision and lobe. quadriplegia. However, residual weakness of his right hand and leg remained, with loss of pain and temperature on his left side below the level of the nipple line. It was not until 1975 that he was doc umented as having a crossed-quadrant homony mous hemianopsia visual field defect on Gold mann visual field testing (Fig. lA and B) while undergoing a routine eye examination. No further management was undertaken at this time. The patient was diagnosed as having type II hy perlipidemia in 1978 and his past surgical history included appendectomy in 1938, transurethral re section of prostate in 1978, and right inguinal her nia repair in 1979. In 1985 examination showed corrected vision of 20/20 for both eyes, normal in traocular pressure measurement, and visual field testing of a crossed-quadrant hemianopsia. In June 1986, while reversing a boat trailer, he twisted his neck and suffered a syncopal attack and total loss of power to the right hand. He was reviewed by both a neurologist and neurosurgeon and under went investigation with plain radiography of the cervical spine, CAT scan of cervical spine, and cer vical myelogram. The radiographs showed previ From the Department of Surgery, Division of Ophthal",lol ous fracture of the fifth cervical vertebra with par ogy, a.A.D., L.W.H.) Princess Alexandra Hospital, and Wick ham Terrace, (K. V., T.C., P.R.M.) Brisbane, Australia. tial bony ankylosis to the fourth and sixth cervical Address correspondence and reprint request to Profes~or vertebra but no other bony or soft tissue pathol Lawrence W. Hirst, 2nd Floor, Lions Clinical Research Build ogy. ing, Ipswich Road, Woolloongabba, Brisbane, Queensland 4102, Australia. In May 1987 the patient had an episode of severe Supported in part by the Australian Foundation f~r the Pre transient pain in the left temporal region associ vention of Blindness (Queensland Division), The Pnncess Al ated with right hemiparesis. He was again seen by exandra Hospital, and the Royal Brisbane Hospital, Brisbane, Australia. his neurologist and underwent CAT scan of the

219 220 J. A. DYER ET AL.

1A 1!HIUflll ." 1!riI1._

1:Io-r-•• .", -.

./ /

~ -- ,.. ••1·. "I I .... .It-- ::;' I -- FIG. 1. A: Goldmann visual field of left eye. B: Goldmann visual field of right eye demonstrating crossed-quadrant homonymous hemianopsia with central isthmus of intact vision. ..,.

\---

': .~' t>,

I •.• ..'

head and a carotid duplex scan. The CAT scan was normal. Humphrey's computer field analysis (Fig. 2) demonstrated a low-density region in the (Fig. 3A and B) demonstrated crossed-quadrant left occipital lobe consistent with old cerebral in homonymous field defect. farct. The carotid duplex scan was within normal On November 23, 1987, the patient underwent a limits. magnetic resonance imaging (MRI) scan (Fig. 4), In August 1987 the patient was referred for fur which demonstrated both right and left occipital ther ophthalmological evaluation. Examination at pole disease with the lesions on the left side being that time showed corrected visual acuity 20/20 in more extensive than those on the right. each eye and reading vision of N4.5 in the right eye and N5.0 in the left eye for near. Pupil reac DISCUSSION tions were normal with no evidence of an afferent pupil defect. Extraocular motility was full and op Cases of crossed-quadrant homonymous hemi tokinetic nystagmus testing was normal in all di anopsia are rare. The most recent article (1) re rections. Corneal sensation was equal in both eyes. viewed nine cases of this condition, documented Intraocular pressure measurement by pneumoto worldwide from 1891 to 1982. Although the re nometry was 15 mm Hg for both eyes. He had ports of these cases were incomplete in areas due evidence of an early anterior supcapsular cataract to data availability, the authors noted some impor change in the left lens. The fundus examination tant characteristics of this visual field defect.

/ Gin Neuro-ophllwlmol, Vol. 10, No.3, 1990 CROSSED-QUADRANT HOMONYMOUS HEMIANOPSIA 221

~ ", I '-- ,... •_ "'.11 I ... ,. l- • 'I ~. I 3.1. I ,,... I II to .pr • IC' I ,- ", I'~ II rIO' ... I ,', I Ir [1':d".11 ", II • •I" "J". r I '-,11 ~ I., I' /. I

H.r·! r. '--':"1 8

FIG. 2. CAT scan. Note low density region in left oc .,....j. cipital lobe consistent with old cerebral infarct (ar A. I,', • , '1;" I. I ''" .11....1' ." I :. I· .- " ·~,r- J ••",. row). r:- ,,'1. ., I"L .....

1. The defects may arise in (a) two simultaneous quadrantanopsias; (b) two successive homony mous hemianopsias, each resolving into a quad rantanopsia; or (c) simultaneous bilateral homon ymous hemianopsias resolving into crossed quadrant defects. 2. The defects usually extend across the hori zontal meridian but respect the vertical midline. 3. There may be sparing of the monocular tem poral crescent. 4. Central vision is usually preserved with a small isthmus of unaffected field connecting the two intact quadrants. 5. The intact quadrants may demonstrate small areas of field loss. 6. Color vision may be abnormal. I _ ..'. , ~ ~III""~•I )~ 7. Riddoch phenomenon may be present, ac "I, .j "'. I-,! i, -,- I "~.:..' • '- 1,__1 I" I .. I•I .11 I, counting for an apparent incongruity of field test L I • It ....J ing if a different velocity is used when testing FIG. 3. A: Humphrey's computer field analyzer left isopters in different eyes. eye. B: Humphrey's computer field analyzer right eye. 8. Simple or complex visual hallucinations may Crossed-quadrant homonymous field defect is dem appear in the blind or seeing field. onstrated in both eyes. Symonds and MacKenzie (2) have studied the origin of bilateral hemianopsias in some detail. sentation. The most frequent cause was emboliza They noted visual field loss was sudden or gradual tion of the calcarine arteries (from basilar or verte and could be affected either simultaneously or in bral branches), or thromboembolism from associ succession, with the former the more common pre- ated cardiac disorders.

J Clin Neuro-ophtlullmol, Vol. 10, No.3, 1990 222 ]. A. DYER ET AI.

The underlying etiology in this c ._ l~ most likely associated with vertebrobasilar disease or posterior cerebra! ischemia from the original cervi cal spine injury. Treatment of patients with this field defect is dependent on the extent of the de fect. The use of both mirror or "checkerboard" prisms have been reported in the literature with varying degrees of success (~5). This case report illustrates many of the impor tant characteristics discussed by Cross and Smith (1), and is the first case documented by computer ized field analysis and MRI scanning.

REFERENCES 1. Cross SA, Smith JL. Crossed-quadrant homonymous hemi anopsia. The "checkerboard" field defect. / Clin Neuro Oph thaimol 1982;2:149-58. 2. Symonds C, MacKenzie I. Bilateral loss of vision from ce rebral infarction. Brain 1957;80:415-55. 3. Walsh 11, Smith JL. Hemianopic spectacles. Am / Ophthal mol 1966;61:914-5. 4. Mintz MJ. A mirror for hemianopia. Am I Ophthalmol 1979;88:768. FIG. 4. Axial MRI scan. Demonstrating both right and 5. Smith JL, Weiner IG. Hemianopic fresnel prisms. / Clin left occipital pole disease (arrows). Neuro OphthalmoI1982;2:19-22.

J 0", t'.·