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Binasal Hemianopia J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.5.697 on 1 October 1973. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry, 1973, 36, 697-709 Binasal hemianopia J. E. A. O'CONNELL AND E. P. G. H. DU BOULAY From St. Bartholomew's Hospital, London SUMMARY Three patients with nasal visual field defects are described. In each case it is believed that compression of the lateral fibres of the optic nerve by the anterior cerebral or internal carotid artery was the cause. Binasal hemianopia can thus be produced by a single lesion and is as much a true hemianopia as the common bitemporal one. The value of careful neuroradiological investiga- tion to display the relationships of a tumour to the chiasma, optic nerves, and related vessels and thus explain the field defects is demonstrated. Isolated loss of the nasal fields of vision is un- nized during the middle of the last century, the common. In Traquair's Clinical Perimetry (Scott, passage of time and increasing experience were 1957) it is stated that the term hemianopia is necessary before these methods of clinical Protected by copyright. best reserved for bilateral field defects produced investigation could be fully utilized. During the by a single lesion-chiasmal or suprachiasmal. same period the pathology of compression of the This author considered that binasal hemianopia optic nerves and chiasma attracted considerable was not a true hemianopia, since its occurrence attention and a number of descriptions of in- indicated bilateral involvement of the uncrossed volvement of these structures by the Willisian fibres at the chiasma, the crossed fibres remaining vessels, observed at postmortem examination, intact. This could be due to displacement of the appeared. In 1852 Turck described the necropsy terminal parts of both optic nerves against the findings in a patient with a pituitary tumour who internal carotid arteries in internal hydroceph- had total blindness in the left eye with some alus: atherosclerosis or aneurysms of both residual vision in the right one. Both optic internal carotid vessels could lead to compression nerves were deeply grooved by the anterior of the nerves in the same area: symmetrical cerebral arteries and on the left the optic tract gummata or other lesions could produce a simi- was also grooved; at the site of compression the lar result. Duke-Elder (1971) also takes the view left optic nerve was reduced to an empty sheath- that bilateral symmetrical lesions at the chiasma there being preservation of the medial one-third are necessary for the development of binasal of the right one. Knapp (1873) had stated that http://jnnp.bmj.com/ hemianopia, though he suggests that bilateral sclerosis of the intracranial internal carotid occipital lesions might produce such a defect. arteries could cause blindness. Smith (1905) From a list of possible causes those due to pres- reported his postmortem finding of atrophy of sure which are mentioned are atherosclerosis or both optic nerves secondary to atherosclerosis of aneurysms of the internal carotid arteries com- the supraclinoid portion of the internal carotid pressing the terminations of both optic nerves, arteries. He had seen altogether six such cases in or displacement of the nerves against blood ves- dissecting and postmortem rooms in Cairo. He on October 1, 2021 by guest. sels by a local tumour, or a distended third refers to the second edition of Fuchs's Textbook ventricle in internal hydrocephalus. It is hoped of Ophthalmology published in the United States to show in this paper that binasal hemianopia in 1903 as also describing such cases. In 1905 can result from a single intracranial lesion and Sachs, cited by Fay and Grant (]928), described that, though rare, it is therefore as much a true the necropsy findings in 48 cases of pituitary hemianopia as is the common bitemporal one. tumour and noted that in two the optic nerves Although the importance of ophthalmoscopy were grooved by the anterior cerebral arteries. and visual field examination began to be recog- Bartels (1906) cited Erdheims's account of seven 697 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.5.697 on 1 October 1973. Downloaded from 698 J. E. A. O'Connell and E. P. G. H. du Boulay necropsy specimens in which the optic nerves tumours; excellent photographs demonstrate the and chiasma were grooved by the anterior grooving of the nervous structures by the vascu- cerebral or anterior communicating arteries, or lar ones in these postoperative cases. The the optic tract by the internal carotid artery. relationship of the findings to the field changes is Bartels also described a case of his own in which by no means clear and it would seem that post- the tracts were grooved by the anterior cerebral operative swelling of residual tumour tissue arteries. Uhthoff (1911) described another such accounted in some measure for the postmortem case where the anterior cerebral arteries con- findings. stricted the optic nerves. It will be seen that all these studies have been Sixty years ago, in a number of papers, based on the examination of postmortem Cushing and Walker reported their careful material. With the development of neurological studies of the visual fields in patients with intra- surgery, and resulting accurate diagnosis and cranial tumours; among these was one on binasal successful surgical treatment of tumours in the hemianopia which appeared in 1912. These sellar region, the opportunities for such post- authors had noted in patients with optic atrophy mortem examinations dwindled. At the same secondary to high intracranial pressure that, time the surgeon's goal would be to excise the where some vision had been retained, this was lesion with minimal trauma and the wide expo- usually in the temporal fields. They suggested sure possible at postmortem examination would that the uncrossed fibres at the chiasma were not be obtained. Perhaps for this reason, rela- damaged not only at the nerve head by develop- tively little has been said in recent years concern- ing scar tissue here, but also close to the chiasma ing the involvement of the optic chiasma, nerves,Protected by copyright. as a result of pressure of the nerves against the and tracts by related vessels and its possible internal carotid arteries occasioned by distension relationship to the production of visual field of the third ventricle. The visual acuity was so defects. It is probable that many surgeons have reduced in their patients that it is extremely noticed grooving of the optic nerve or chiasma doubtful if the small islands of temporal vision by the anterior cerebral artery in operating for which persisted justified the diagnosis of binasal pituitary tumours and some have related this to hemianopia. Hirsch (1921) described grooving an inferior quadrantic nasal field defect on the of both optic nerves by both anterior cerebral affected side (Schneider et al., 1970). arteries and of the chiasma by the anterior com- Modern methods of investigation and their municating artery as a necropsy finding in a skilful interpretation can provide very full patient with a pituitary tumour. Fay and Grant information concerning the relationship of the (1923) provided a good review of the literature optic nerves and chiasma, the Willisian vessels, and described a case of interpeduncular cranio- and an associated tumour mass to one another. pharyngioma, which had displaced the chiasma With the single exception of the bony landmarks anteriorly so that the optic tracts on both sides of the posterior margin of the optic canal in the http://jnnp.bmj.com/ were grooved by the internal carotid arteries, lateral skull view, the radiological anatomy is the left one also being grooved by the anterior well known. The pneumographic appearance of cerebral artery. These authors attributed the the chiasmatic cistern was described in detail by nasal portion of the severe visual field disturb- Dilenge in 1955 and by Liliequist in 1959. Bull ance in this patient to vascular notching of the (1955) has made a detailed study of the normal optic tracts. Balado and Malbran (1933a, b) variations in the position of the optic recess of discussed involvement of the optic nerves, tracts, the third ventricle and Gado and Bull have and chiasma by related arteries in the presence of recently (1971) shown the many ways in which on October 1, 2021 by guest. pituitary tumours, cerebral tumours in various the anterior cerebral arteries may be displaced situations, and internal hydrocephalus. In addi- by suprasellar masses. tion, they describe three patients with binasal In the normal patient the pre-communicating hemianopia and in each case relate this to the parts of the anterior cerebral arteries bear a postmortem findings. Rucker and Kernohan fairly constant relationship to the chiasma and (1954) described the necropsy findings in five may, of course, be demonstrated by angio- patients who died after surgery for pituitary graphy, but a more precise localization of the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.5.697 on 1 October 1973. Downloaded from Binasal hemianopia 699 FIG. 1. Case 1. Fields of vision. Protected by copyright. optic chiasma and the intracranial parts of the of their course, even after the most careful optic nerves is possible both in the normal and pneumography in cases of pituitary adenoma. the abnormal patient by observation of certain However, just as the attachment of the chiasma other anatomical features shown during the to the third ventricle can virtually always be various radiographic examinations. At both shown even in abnormal cases (by pneumo- pneumoencephalography and ventriculography encephalography), so can the anterior point of the impression made by the optic chiasma on the attachment of the optic nerves at the skull base anterior end of the third ventricle, between the be recognized on lateral plain radiographs and optic and infundibular recesses, may, itself, this localization may be transferred to lateral regularly be seen.
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