H53.413 Visual Field Defect

Visual defects are localized defects in a person’s visual field. They can occur from a variety of causes such as trauma to the brain or visual pathway, diseases and disorders of the eye, optic nerve or the brain and systemic vascular disease.

Structural Damage to the Eye

• Damage of retinal ganglion cells
• Damage of visual cortex or neurological visual pathways

Functional Damage to the Eye

• Associated visual field defects 

The main goal of the diagnostic evaluation for a patient with visual field defect is to accomplish the following: 

• Determine the etiology of the visual defect
• Determine the structural and/or functional damage to the eye
• Develop a treatment plan

Patient History

Patients with visual field defects will have the following abnormal clinical signs and symptoms:

• Visual distrubances
• Isolated regions of vision loss
• Overall loss of vision, blur, discomfort  of vision

Additional factors to determine in the patient history:

• Is the vision loss sudden or gradual
• Does he visual field defect appear to be a spot, a region of blur or does the overall view of objects has missing parts
• Did the patient have any recent history of trauma
• Does the patient have a history of eye diseases such as glaucoma, optic nerve disorder, neurological disorder or vascular disease
• Did the patient have a recent stroke or heart attack

Clinical Appearance of the Retina Look for signs of damage to the vascular system of the eye (i.e. central retinal vein or central aterial occlusion and vitreous hemorrhages)

DIAGNOSTIC TESTS

The main goal of the diagnostic testing is to accomplish the following:

• Confirm the etiology of the visual field defect
• Determine the extent of the visual field defect
• Determine the structural and functional damage to the eye
• Evaluate progression or improvement of visual field defect over time

Refraction

•  Measurement of visual function / visual acuity

Visual Field Examination

•  Various visual field defects will be present depending on the cause

30-2 Threshold Visual Field Examination Central visual field defect corresponding to vascular disease

Extended Ophthalmoscopy

• Evaluate optic disc morphology
• Document abnormal structural changes to the optic disc
• Evaluate the retina and document abnormalities to the retina and the retinal vasculature

There are several types of visual field defects:

Arcuate scotomas refer to loss of vision around the optic nerve and tend to be related to glaucoma.

Nasal step scotomas refer to loss of vision around the area of the optic nerve and tend to be related to glaucoma.

Central Scotoma refers to loss of vision centrally and can be associated with macular degeneration, macular edema and central serous detachments are a few causes.

Altitudinal Defects refer to loss of vision above or below the horizontal and tend to be associated with ocular abnormalities or vascular disease.

Heteronymous Hemianopia refers to loss of vision on the opposite sides of both eyes and tends to be associated with defects before or at the optic chiasm. A visual field examination showing a visual defect of the temporal side is refered to as\ a bitemporal hemianopia. A visual field examination showing a visuals loss of the nasal side is called a binasal hemianopia.

Homonymous Hemianopia refers to loss of vision on one side of both eyes and tends to be associated with defects behind the optic chiasm.

Macular degeneration

• Some patients may have central visual field defects related to the macula.

Retinal Detachments or Tears

• Patient with retinal detachments or tears can also experience visual field defects.

Ocular Migraines 

• Some visual disturbances during an ocular migraine can mimic vision and visual field
  loss.

Dermatocholasis

• Excessive dermatocholasis can simulate visual field defects on perimetry examination
  and perceived visual field loss from the patients perspective

Find out cause of visual field defect and treat according to the cause

Systemic causes related to vascular or neurological issues need to be directed to the patient’s primary care physician to resolve the underlying systemic. Sudden onset of visual field defects requirement immediate action to find the cause, especially if it is vasculature related and to refer if appropriated. Fluorescein angiography may be recommended depending on the cause and referral to a retinal specialist may be appropriate in some cases. Long term on gradual visual field defects can be monitor with visual field examination after the cause is determined.

Eye disease or optic nerve disease should be treated according to the cause of the visual loss. Please refer to the appropriate disease glossary topic related to the cause of the visual field defect for further details on that particular disease.

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