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Crossed-quadrant homonymous hemianopsia in a monocular patient

Published:March 02, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.02.004
      A 75-year-old male presented to the clinic reporting that upon waking up from a nap 4 days earlier, he noticed he could “only see in certain spots.” He has an ocular history of moderate-stage primary open-angle glaucoma in both eyes, dry eye syndrome, and pseudophakia. He had previously undergone enucleation of his blind, painful right eye due to neovascular glaucoma from a previous central retinal vein occlusion. He was a former smoker, and his medical history is significant for multiple myeloma, bladder cancer, pulmonary embolism, hypertension, and hyperlipidemia.
      On initial examination, his visual acuity was 20/25-2 OS with intraocular pressure of 13 mm Hg OS and 3 out of 11 colour plates. He wore a prosthesis OD. Examination of the anterior segment and fundus of his left eye was stable from previously documented examinations, including careful examination of the optic nerve. Optical coherence tomography imaging of the retina was within normal limits. Confrontational visual field testing with a colored target revealed possible left hemi-field loss. Humphrey Central 24-2 Threshold visual field testing revealed new deficits that were not present on testing performed 3 months prior, as seen in Figure 1.
      Fig 1
      Fig. 1Humphrey Central 24-2 Threshold visual field testing of the left eye from 3 months prior to presentation (left) and day of presentation (right). The visual field demonstrated the juxtaposition of a left superior quadrantanopsia and a right inferior quadrantanopsia resembling a crossed-quadrant homonymous hemianopsia.
      Despite the patient's monocular status, it was believed that the automated perimetry demonstrated a combination of a left superior quadrantanopsia with a right inferior quadrantanopsia resembling a crossed-quadrant homonymous hemianopsia (CQHH). The patient was sent to the emergency department for urgent stroke evaluation and neurology consultation. Magnetic resonance imaging of the brain revealed bilateral acute occipital lobe infarcts—one infarct located along the left superior calcarine bank, and one infarct located along the right inferior calcarine bank, as demonstrated in Figure 2.
      Fig 2
      Fig. 2Magnetic resonance imaging shows bilateral occipital lobe infarctions. The left infarct is superior to the calcarine fissure (A) and the right infarct is inferior to the calcarine fissure (B). The patient was also found to have a remote infarct of the left parieto-occipital lobe (C).

      Discussion

      The unique entity of CQHH or “checkerboard visual field defect” is exhibited when consecutive or simultaneous occipital lobe lesions occur superior to the calcarine fissure and inferiorly on the contralateral hemisphere.
      • Cross SA
      • Smith JL
      Crossed-quadrant homonymous hemianopsia. The "checkerboard" field defect.
      Automated perimetry in our monocular patient disclosed a pattern resembling a CQHH or the striking “checkerboard visual field defect”—in this case, the juxtaposition of a left superior quadrantanopsia and a right inferior quadrantanopsia. This pattern is essentially pathognomonic for bilateral occipital lesions.
      A suspicion of CQHH should prompt urgent stroke evaluation, particularly in an elderly patient such as ours with vasculopathic risk factors as well as multiple myeloma and bladder cancer, further increasing his risk of thromboembolism. The most common cause of CQHH, as in our patient, is an ischemic or hemorrhagic infarct that may be associated with a thromboembolic event, dissection, or cervical vertebral trauma, but CQHH has also been reported with tumors, migraine, syphilis, necrotizing ependymomyelitis, and demyelinating disease.
      • Cross SA
      • Smith JL
      Crossed-quadrant homonymous hemianopsia. The "checkerboard" field defect.
      • Cesareo M
      • Pozzilli C
      • Ristori G
      • Roscioni M
      • Missiroli A.
      Crossed quadrant homonymous hemianopsia in a case of multiple sclerosis.
      • Dyer JA
      • Hirst LW
      • Vandeleur K
      • Carey T
      • Mann PR.
      Crossed-quadrant homonymous hemianopsia.
      • Tamhankar MA
      • Markowitz CE
      • Galetta SL.
      Checkerboard fields in multiple sclerosis.
      Most of the cerebral infarcts that cause CQHH are derived principally by embolization of the calcarine arteries from the P3 branch of the posterior cerebral artery.
      • Cesareo M
      • Pozzilli C
      • Ristori G
      • Roscioni M
      • Missiroli A.
      Crossed quadrant homonymous hemianopsia in a case of multiple sclerosis.
      Our patient had bilateral occipital lobe infarcts located along the left superior calcarine bank and right inferior calcarine bank.
      To the best of our knowledge, we describe the first report of a CQHH diagnosed in a monocular patient. From this case, several important clinical pearls should be considered. First, the possibility of a homonymous field defect should always be considered in monocular patients with new visual field deficits. Second, in patients with glaucoma who present with new visual field loss, the clinician should always consider whether the visual field deficit corresponds with the appearance of their optic nerve. Third, visual field deficits can be detected with increased sensitivity on confrontational visual field testing by using a red target instead of a white target or counting fingers. This is consistent with the assertion by Pandit et al. that use of a small red target is the most sensitive method for examination of central 20° visual field and was crucial to the prompt diagnosis in this patient.
      • Pandit RJ
      • Gales K
      • Griffiths PG.
      Effectiveness of testing visual fields by confrontation.
      Lastly, the clinician should have a low threshold for obtaining formal visual field testing in an expedited fashion, particularly in patients with significant vasculopathic risk factors and when the ophthalmologic exam cannot explain the visual field deficit.

      Footnotes and Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.
      Written patient consent was obtained, and all patient identifiers were removed from the submission. Full adherence to the Declaration of Helsinki and all Federal and State laws.

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