Homonymous Hemianopia

History Taking

Chief Complaint

• Patient reports loss of vision in one half of the visual field in both eyes

History of Presenting Complaint

• Patient noticed difficulty in reading text, problems with navigating around unfamiliar places, or bumping into objects on one side

• Difficulty with driving, particularly noticing cars or pedestrians on one side

• The vision loss may have been sudden or gradual

• Associated pain, redness, or discomfort in the eyes

• Alteration in color perception

System Review

• Auditory or sensory changes

• Difficulty in speaking or understanding language

• Difficulty in remembering new information or recognizing familiar places or people

• Physical weakness or numbness

• Episodes of loss of consciousness or convulsion

• Headache or vomiting

Past Medical History

• History of cerebrovascular accidents (stroke), transient ischemic attacks, or any other vascular pathologies such as hypertension or hyperlipidemia

• History of brain tumor or brain surgery

• History of any neurodegenerative conditions like Alzheimer's or Parkinson's disease

• History of traumatic brain injury

Drug History

• Anticoagulant or antiplatelet medication for vascular conditions

• Antihypertensive medication

• Medication for any diagnosed neurological conditions

Family History

• Family history of vascular diseases, such as stroke or heart disease

• Family history of brain tumors or neurodegenerative conditions

Personal History

• Smoking and alcohol consumption, as these can contribute to vascular disease

• Any sudden changes in diet or lifestyle

Social History

• Changes in ability to work or perform daily activities due to vision loss

• Impact on driving or travel due to the vision loss

• Living situation – living alone could increase risk of accidents due to impaired vision

Travel History

• Exposure to certain infectious diseases that could potentially affect the brain, like malaria or neurocysticercosis

Vaccine History

• Vaccination status against diseases that can potentially cause neurological complications, like meningitis, measles, etc.

Physical Examination

General Examination

• Patient is alert and oriented

• Evidence of previous cranial surgery

• Signs of trauma or injury if there's a history of traumatic brain injury

Hands and Arms

• Signs of peripheral cyanosis or clubbing

• Abnormal movements or tremors

Face (Eyes, Nose, Mouth)

• Visual field loss detected by a confrontational visual field test

• Pupils are unequal in size or not reactive to light

• Abnormalities in the external appearance of the eyes

• Pallor or jaundice

Neck

• Carotid bruits present in the case of carotid artery disease

Cardiac Examination

• Presence of irregular rhythm or murmurs indicate a cardiac source of emboli leading to cerebrovascular accidents

Neurological Examination

• Involvement of homonymous hemifield in both eyes, identified with formal perimetry testing

• Abnormal ocular movements and pupil reactions

• Abnormalities found in fundoscopic examination

• Abnormal motor and sensory examination of the limbs

• Abnormal gait and coordination

• In case of stroke, signs of focal neurological deficits

Additional Examination

• Cognitive function assessment shows signs of neglect or anosognosia if the lesion is in the right parietal lobe

• Visual neglect tests indicate neglect syndrome which could be seen with right-sided lesions

Investigations

Laboratory Tests

• Full blood count: to assess for anemia or infection

• Coagulation profile: necessary if considering anticoagulation therapy or if the patient is already on anticoagulants

• Blood glucose and HbA1c: to identify or monitor diabetes, a risk factor for vascular disease

• Lipid profile: hyperlipidemia is a risk factor for cerebrovascular disease

• ESR and CRP: if suspecting vasculitis as a cause

• Serological tests for syphilis, HIV, or other relevant infections if indicated by history

Imaging

• CT or MRI brain: to identify the location of the lesion and the nature of the pathology (stroke, tumor, etc.)

• CT angiography or MR angiography: to assess the cerebral vasculature if a vascular lesion is suspected

• Carotid ultrasound: if carotid artery disease is suspected

Invasive Tests

• Lumbar puncture: if considering a diagnosis of central nervous system infection or inflammation

• Carotid endarterectomy: if there is significant carotid artery stenosis causing repeated transient ischemic attacks or strokes

Other Tests

• Electrocardiogram (ECG): to look for atrial fibrillation or other cardiac arrhythmias which could be a source of emboli

• Echocardiography: if a cardioembolic source of stroke is suspected

• 24-hour ECG (Holter monitor): if paroxysmal atrial fibrillation is suspected

• Visual field testing: to confirm and quantify the homonymous hemianopia

• Neuropsychological assessment: if cognitive impairment is suspected

Management

General Management

• Lifestyle modifications: diet, exercise, smoking cessation, moderation of alcohol intake

• Education: awareness about the condition, visual strategies and safety measures to compensate for visual loss

• Occupational therapy: may help in optimizing patient's abilities in daily tasks

• Driving restrictions: as per local regulations, may need to stop driving until declared safe by a professional

Medical Management

• Blood pressure control: use of antihypertensives if necessary

• Lipid control: statins could be used in case of dyslipidemia

• Glycemic control: antidiabetic medications for those with diabetes

• Antiplatelet agents: aspirin or clopidogrel, particularly in those with non-cardioembolic ischemic stroke

• Anticoagulants: warfarin or direct oral anticoagulants (DOACs) if the stroke is of cardioembolic origin

• Treat any identified underlying condition: e.g., antibiotics for infection, immunosuppressants for vasculitis

Surgical Management

• Carotid endarterectomy or stenting: if significant carotid stenosis is found

• Neurosurgical intervention: for removal of tumors, if they are the underlying cause of homonymous hemianopia

Other

• Vision restoration therapy: involves computer-based visual exercises

• Prism glasses: can be helpful for some patients

• Regular follow-up: for monitoring progress and adjusting treatment as necessary

• Multidisciplinary approach: neurologist, ophthalmologist, occupational therapist, and psychologist involvement as needed