VEASEY: a Case of Bitemporal Hemianopsia

VEASEY: A Case of Bitemporal Hemianopsia. 383 OBSERVATIONS OF A CASE OF BITEMPORAL HEM- IANOPSIA WITH SOME UNUSUAL CHANGES IN THE VISUAL FIELDS. ty CLARENCE A. VEASEY, M.D., PHILADELPHIA, PENN. The following case of bitemporal hemianopsia has seemed to the writer to present some unusual features of sufficient interest to merit its isolated report. G. P. S., a married traveling salesman, 34 years of age, con- sulted me first on May 27, I903, and presented the following history: His general health had always been excellent and his appearance so indicated, as he was about six feet in height and weighed about I70 pounds. There was no history of any ocular trouble in his family, and though he began to wear glasses at i6 years of age, for a low compound hyperopic astigmatism, his eyes had given him no trouble except the headaches, which the glasses had corrected. Early in January, or six months before I first saw him, there had gradually appeared a "'fogginess " of the temporal half of each field of vision, which, he thinks, was noticeable in the right eye before it was observed in the left. He placed himself under the care of a homeopathic oculist, who gave him as much as fifty grains of iodide of potassium three times a day, and this dose he had been taking for some months. Specific history was denied and there were no other symptoms to cause its presence to be stuspected. The urinary and blood examinations were negative. Ophthalmoscopically, all the fundus details were normal and have continued so to the present time. There is no blurring of the disc edges nor pallor of the nerve heads in any part. The fields of vision taken at the time of my first examination (May 27, I903), showed bitemporal hemianopsia with the light sense still preserved in the hemianopic halves. (Fig. i.) The divid- 384 VEASEY: A Case of Bitemporal Hemianopsi. ing line was almost vertical in the right eye and passed directly through the fixation point, the patient stating that the round ivory disc in the center of the perimetric arc appeared as a semi- circle. In the left eye the dividing line was inclined slightly to the right in the upper portion, and the fixation point was included in the preserved half of the field.. Vision equaled 6/30, eccentrically, in the right and 6/I5 in the left eye, but with both eyes 6/7.5 could be read slowly. The visual fields, taken at frequent intervals, continued in practically the same condition until June igth, a period of a little more than three weeks. On this date there was absolute bemi- anopsia in the right eye, the dividing line passing slightly to the right of the fixation point, the light sense being still preserved in the left. On June 22d the light sense had returned in the former blind portion of the right eye, and the dividing line passed nearly 50 to the right of the fixation point, affording normal visual acuity. In the left eye the light sense was preserved only in the outer half of the temporal field. (Fig: 2.) During inhalation of amyl nitrate the fields cleared greatly, the patient being able to count fingers, distinguish objects (lead pencil, bottle, hand, etc.,) in the portion of the fields in which the light sense was preserved, though the " fogginess " remained. On July i ith the temporal field of the right eye was absolutely hemianopic, the fixation point now being in the blind field; and in the left the light field was still preserved. On August 8th there was found a very great change. In the right eye only the upper inner quadrant of the field was preserved, the remainder having lost all visual sense; and the dividing line passed about 20 to the left of the median line and fixation point. In the left eye light perception was still preserved in the outer field; but the dividing line now passed about ioo to the left of the fixation point, and beyond this was an area 30 wide in which form and color could be distinguished, thQugh hazy; in other words the area was relatively scotomatous. (Fig. 3.) Vision in the right eye now equaled 3/IOO eccentrically; in the left 6/6. i. '08 8 k\.~~~~~~~~~~~~~~~~~~~~~~~~'Id0.gIA Lo La LO -. wrDI: VEASEY: A Case of Bitemporal Hemianopsia. 385 On October ioth the lower quadrant of the right field, that had been lost at the time of the last examination, was entirely restored. The dividing line passed through the fixation point, and vision equaled 6/22.3, slightly eccentrically. Vision in the temporal half remained totally abolished. The field of the left eye showed form perception in a larger area than before, light perception being still preserved in the outer half. (Fig. 4.) Since this time, a period of nine months, there has been but little variation in the character of the fields at any examination. At the present time about the only change from the examination just described is that the relative scotoma in the left eye is slightly larger, meaning restored vision- in a larger portion of the former. blind field. The light sense is still present in the left, but lost in the right temporal field. t (Fig. 5.) The vision in the right eye is 6/I2, eccentrically, and in the left 6/6. A skiagraphic examination of the brain of this patient shows a distinct shadow in the region of the chiasm. In presenting this skiagraph, I fully realize the skepticism regarding ski- agraphy of cerebral lesions, even when of large size, and the method has certainly proved of very little vallie thus far except in furnishing corroborative evidence in those cases in which the diagnosis and the location had been previously determined by other means. In the skiagraph herewith presented, however, it is possible, if. it be held about a meter distant from the eyes, and in such a position that the light will be reflect¶d from its surface, to observe distinctly a shadow in the area indicated by the arrows, and concerning which the skiagrapher, Dr. G. E. Pfahler of Philadelphia, who has had a large experience in this line of work, writes as follows: "The X-ray examination of the head of Mr. G. S., made January 23, 1904, shows a small and rather faint shadow, which is denser than the surrounding brain tissue, lying five-eighths of an inch above the floor of the Sella Turcica. This shadow is one- half inch in length and three-eighths of an inch in height. A tumor of this size lying at the middle of the brain could not be expected to cast a more dense shadow than that which is obtained 386 Discussion. in this skiagraph. The detail is always a little more clearly shown in the negative than in the print. " In addition to the above, the anterior clinoid processes are about twice the length of the shadows obtained in any other head that I have examined." In the line of treatment the patient has received almost every- thing that suggests itself in this class of cases. Mercurial in- unctions, large doses of potassium iodide, pilocarpin sweats, sali- cylate of sodium, and thyroid eytract have all been tried, but without appreciable effect. As to the etiology, there is probably a small tumor in front of the chiasm, of a more or less vascular nature, that changes its size, and thereby the amoutft of pressure, from time to time, thus producing the alterations of the visual fields as described, the pressure not being sufficient to produce atrophic changes in the nerve-heads. There is no history nor any indication of syphilis, and hysteria can be absolutely eliminated. Whether the lesion is an aneurism of an anomalous artery, as in the case of Weir Mitchell and Dercum, or a solid vascular tumor, it is impos- sible to say; but it has been observed frequently during the treatment of the case that the fields were always worse in damp, cloudy weather, though the patient is only vaguely rheumatic; and he himself has frequently remarked that the " fogginess " seemed to be less dense when he was under the influence of anti- rheumatic remedies. DISCUSSION. DR. G. C. IlARLAN.- I believe such well-defined cases are rare. I can recall two in my experience. One is a case that some of the members may remember my reporting some years ago: a sailor from a South American port, with obscure cerebral symptoms, and finally this bitemporal hemianopsia appeared. The man described his condition as like that of a horse with a pair of large blinders. Microscopical examination of the blood showed Lavaran corpuscles and the cerebral symptoms disap- peared, and with them the hemianopsia, under large doses of quinine. .......................... mmi!gg. g --N al W`11140sl -..j VEASEY-Bitemporal Hemianopsia. VEASEY: Macular Degeneration of the Cornea. 387 In a second case, which I have since had, a young married woman, entirely free from any neurotic condition, noticed a little confusion of vision, and on examination it was found that in the right eye the field was limited on the temporal side. This limitation extended until, at the end of seven months, it had reached the median line. The ophthalmoscopical examination was negative, and the patient was otherwise in a perfectly healthy condition. Not long afterwards the outer field of the other eye commenced to fail, and the limitation progressed until it also reached the vertical middle line.

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