Original Paper Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
Received: September 9, 2013 Accepted: October 10, 2013 Published online: January 16, 2014
Clinical Study of the Visual Field Defects Caused by Occipital Lobe Lesions Katsuhiko Ogawa a Hiroshi Ishikawa b Yutaka Suzuki a Minoru Oishi a Satoshi Kamei a a
Division of Neurology, Department of Medicine, and b Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Tokyo, Japan
Abstract Background: The central visual field is projected to the region from the occipital tip to the posterior portion of the medial area in the striate cortex. However, central visual field disturbances have not been compared with the location of the lesions in the striate cortex. Methods: Thirteen patients with visual field defects caused by partial involvement of the striate cortex were enrolled. The lesions were classified according to their location into the anterior portion, the posterior portion of the medial area, and the occipital tip. Visual field defects were examined by the Goldmann perimetry, the Humphrey perimetry and the auto-plot tangent screen. We defined a defect within the central 10° of vision as a central visual field disturbance. The visual field defects in 13 patients were compared with the location of their lesions in the striate cortex. Results: The medial area was involved in 7 patients with no involvement of the occipital tip. In 2 of them, peripheral homonymous hemianopia without central visual field disturbance was shown, and their lesions were located only in the anterior portion. One patient with a lesion in the posterior portion alone showed incomplete central homonymous hemianopia. Three of 4 patients with lesions located in both the anterior and posterior portions of the medial area showed incomplete central homonymous hemianopia and
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peripheral homonymous hemianopia. The occipital tip was involved in 6 patients. Five of them had small lesions in the occipital tip alone and showed complete central homonymous hemianopia or quadrantanopia. The other patient with a lesion in the lateral posterior portion and bilateral occipital tip lesions showed bilateral slight peripheral visual field disturbance in addition to complete central homonymous hemianopia on both sides. Conclusions: Lesions in the posterior portion of the medial area as well as the occipital tip caused central visual field disturbance in our study, as indicated in previous reports. Central homonymous hemianopia tended to be incomplete in patients with lesions in the posterior portion in the medial area. In contrast, complete central homonymous hemianopia and quadrantanopia were shown in patients with occipital tip lesions. Our study suggested that the fibers related to the central visual field were sparse in the posterior portion of the medial area in contrast to the occipital tip, and approached the occipital tip with a high concentration of fibers. © 2014 S. Karger AG, Basel
Introduction
Visual field defects due to lesions of the occipital lobe are usually attributed to damage to the striate cortex [1]. The map presented by Holmes [2] was widely adopted as a detailed representation of the visual field in the human Katsuhiko Ogawa, MD Division of Neurology, Department of Medicine Nihon University School of Medicine 30-1 Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610 (Japan) E-Mail ogawa.katsuhiko @ nihon-u.ac.jp
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Key Words Central visual field · Occipital tip · Striate cortex
inappropriate for the comparison between visual field defects and the locations of lesions in the striate cortex. The locations of occipital lobe lesions were evaluated with computed tomography and magnetic resonance imaging (MRI). The time between the onset of initial symptoms and the radiological study ranged from 14 h to 7 days. The locations of lesions in the striate cortex were classified into the occipital tip and the medial area (fig. 1). Lesions in the medial area were subdivided into anterior and posterior portions in an axial position (fig. 1). Visual field defects were evaluated with Goldmann perimetry, Humphrey perimetry and auto-plot tangent screen. The area of visual field defects was grouped into central and peripheral visual fields. A visual field defect within the central 10° was regarded as a central visual field disturbance. A visual field defect peripheral to the central visual field was regarded as a peripheral visual field disturbance.
Thirteen patients aged 24–84 years (male: 11 patients, female: 2 patients) were enrolled in this study. They were admitted to our hospital from 1985 to 2012 because of visual field defects caused by lesions in the occipital lobe. Occipital lobe lesions in the 13 patients showed partial involvement of the region from the occipital tip to the medial area in the striate cortex. Patients with lesions involving the whole striate cortex and lesions outside the occipital lobe were excluded from this study, because these patients were
Location of Lesions in 13 Patients (table 1) Occipital lobe lesions were identified with computed tomography in 4 patients (patients 3, 7–9) and MRI in the other 9 patients (patients 1, 2, 4–6, 10–13). The MRI findings were evaluated using diffusion-weighted images in 2 patients (patients 2, 5), fluid-attenuated inversion recovery images in 4 patients (patients 1, 4, 6, 12) and T2weighted images in 3 patients (patients 10, 11, 13). The view of the MRI images was axial in all 13 patients. The diagnosis of the occipital lobe lesions was cerebral hemorrhage caused by arteriovenous malformation in 1 patient (patient 7) and brain infarction in the other 12 patients. The lesions of 7 patients (patients 1–7) were located in the medial area in the striate cortex with no occipital tip lesions. In these 7 patients, the lesions were located on one side in 6 patients (patients 1–5, 7). In 1 patient (patient 6), the lesions below the calcarine fissure were located on both sides, while the lesion above the calcarine fissure was located on the left side. Lesions were located in the anterior portion of the medial area in 2 patients (patients 1, 2). In 4 patients (patients 3–6) the lesions involved both the anterior and posterior portions. The lesion of 1 patient (patient 7) was located in the posterior portion of the medial area. On the other hand, the occipital tip was involved in 6 patients (patients 8–13). In these 6 patients, the lesions of the occipital tip were located on one side in 5 patients (patients 8, 9, 11–13) and on both sides in 1 patient (patient 10). The lesions in 5 patients (patients 8, 9, 11–13) involved the occipital tip alone. In 1 patient (patient 10), the lesion on the right side extended to the posterior portion of the medial area from the occipital tip, while the lesion on the left side was located only in the occipital tip.
Visual Field Defects and Occipital Lobe Lesions
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
Fig. 1. Schema of the striate cortex. The medial area (brown) of the
striate cortex is divided into the anterior and posterior portions. The occipital tip (pink area) is located at the pole of the occipital lobe.
striate cortex [3, 4]. On this map, the central visual field was represented at the occipital tip, while the peripheral visual field was mapped anteriorly. In recent years, Horton and Hoyt [1] pointed out the underestimation of the cortical magnification of the central visual field in humans. Other recent studies also reported that the area corresponding to the central visual field expanded to the medial area in the striate cortex [3–6]. However, a comparison between the central visual field disturbances due to lesions of the occipital tip and those due to the medial area in the striate cortex has not been reported. In this study, we studied the characteristics of central visual field disturbances caused by lesions in the striate cortex, based on the investigation of the correlation between visual field defects and the location of lesions in the striate cortex.
Patients and Methods
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Results
Table 1. Breakdown of 13 patients with visual field defects caused by occipital lobe lesions
No./ age/sex
Localization of the lesion side
medial area
Central visual field disturbance (≤10°)
Peripheral visual field disturbance (>10°)
Temporal crescent
− − + (lt. incomplete hom. hemianopia) + (lt. incomplete hom. hemianopia) + (lt. incomplete hom. hemianopia) + (bil. complete superior altitudinal hemianopia) + (lt. incomplete hom. hemianopia) + (lt. complete superior hom. quadrant–anopia) + (lt. complete hom. hemianopia) + (bil. complete hom. hemianopia)
+ (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (BSAH, rt. inferior hom. quadrantanopia) − −
− − − + (lt. eye) + (lt. eye) −
− + (bil. slight)
− −
− −
− −
−
−
tip
anterior posterior portion portion 1/61/F 2/66/M 3/84/M 4/67/F 5/66/M 6/63/M
rt. rt. rt. rt. rt. bil. rt. lt. rt. rt.
+ + + + + + + − −
− − + + + + + + −
− − − − − − − − +
9/53/M rt. 10/45/M bil. rt. lt. 11/62/M lt. 12/58/M lt.
− − − − −
− + − − −
+ + + + +
13/70/M rt.
−
−
+
7/24/M 8/78/M
+ (rt. complete hom. hemianopia) + (rt. complete superior hom. quadrant–anopia) + (lt. complete hom. hemianopia)
− −
Analysis of Visual Field Defects (fig. 2) Disturbance of the visual field was measured with Goldmann perimetry in 11 patients (patients 1–6, 9–13), auto-plot tangent screen in 1 patient (patient 7) and Humphrey perimetry in 1 patient (patient 8).
their visual field defects spread to both the upper vertical meridian and the horizontal meridian. The central visual field disturbance in patient 6 spread to the bilateral horizontal meridians and was bilateral complete superior altitudinal hemianopia.
Central Visual Field Disturbance in 13 Patients (table 1, fig. 2) Central visual field disturbance occurred in 11 patients (patients 3–13). Seven (patients 3–5, 7, 9, 11, 13) showed central homonymous hemianopia on one side. One patient (patient 10) showed central homonymous hemianopia on both sides. Central homonymous hemianopia did not reach the lower vertical meridian in 1 patient (patient 3) and both the upper and lower vertical meridians in 3 patients (patients 4, 5, 7). Accordingly, these 4 patients (patients 3–5, 7) showed incomplete central homonymous hemianopia. In contrast, 4 patients (patients 9–11, 13) showed complete central homonymous hemianopia because their central homonymous hemianopia reached both the upper and lower vertical meridians. Central visual field disturbance in 2 patients (patients 8, 12) was complete central homonymous quadrantanopia because
Disturbance of the Peripheral Visual Field in 13 Patients (table 1, fig. 2) Peripheral visual field disturbance occurred in 7 patients (patients 1–6, 10). Two patients (patients 1, 2) showed peripheral visual field disturbance alone. In the remaining 5 patients (patients 3–6, 10) peripheral visual field disturbance was accompanied by central visual field disturbance. In 5 patients (patients 1–5), peripheral homonymous hemianopia occurred on one side. Goldmann perimetry in patient 10 showed bilateral homonymous hemianopic central scotomas with vertical steps and peripheral visual field disturbance observed almost within 20° on both sides. The peripheral visual field disturbance in 1 patient (patient 6) showed bilateral superior altitudinal hemianopia in addition to inferior homonymous quadrantanopia on the right side. In addition a temporal crescent was present on the contralateral eye in 2 patients (patients 4, 5).
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rt. = Right; lt. = left; bil. = bilateral; hom. = homonymous; BSAH = bilateral superior altitudinal hemianopia.
No.
MRI/CT findings
Visual field defects
1
Rt
Lt
Rt
Lt
Rt
2
Rt 3
Rt
Lt
Rt
4
Rt
Lt
Rt
5
Rt
Lt
Rt
6
Rt Lt
Rt
Rt
(For fig. 2 (patients 7–13) see next page.)
Visual Field Defects and Occipital Lobe Lesions
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
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Fig. 2. Radiological findings and visual field defects in 13 patients.
7
Rt
Lt
Rt
8
Rt
Lt
Rt
9
Rt
Lt
Rt
10
Rt
Lt
Rt
Lt
Rt
11
Rt 12
Rt
Lt
Rt
13
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Rt
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Rt
The Holmes’ [2] map provided the most detailed representation of the visual field in the human striate cortex [5]. However, recent studies pointed out an expansion of the area corresponding to central vision in the posterior part of the striate cortex [3–6]. Horton and Hoyt [5] indicated the underestimation of the cortical magnification of central vision in the Holmes’ [2] map. They reported that the area corresponding to the central visual field within 10° amounted to about 50% of the striate cortex, based on the correlation between the localizations of striate cortex lesions imaged by MRI and visual field defects in humans [5]. According to a study by Wong and Sharpe [4], 37% of the total surface area of the medial occipital cortex corresponded to the central 15° of vision. McFadzean et al. [3] reported that the central 10° of the visual field occupied at least 50–60% of the striate cortex. These three studies suggested that the central visual field corresponds to the posterior half of the medial area in the striate cortex, and the peripheral visual field corresponds to the anterior half [3–5]. In our study, lesions in 7 patients were located in the medial area in the striate cortex, with no occipital tip lesions. Among them, 3 patients with involvement of the anterior and posterior portions of the medial area showed both peripheral homonymous hemianopia and central homonymous hemianopia. On the other hand, peripheral homonymous hemianopia without central visual field disturbance occurred in 2 patients only with a lesion in the anterior portion of the medial area. One patient with a lesion in the posterior portion of the medial area showed central homonymous hemianopia without peripheral visual field disturbance. These results suggested that the responsible lesion for central visual field disturbance extended to the posterior portion of the medial area in the striate cortex, which was consistent with recent studies that reported the responsible lesion for central visual field disturbance [3–6]. Bilateral superior altitudinal hemianopia in 1 patient correlated well with the bilateral involvement of the anterior and posterior portions of the medial area below the calcarine fissure. A lesion above the calcarine fissure on the left side caused right peripheral inferior homonymous quadrantanopia, and this lesion was located slightly more anterior than the location of the lesions below the calcarine fissure. This result might indicate that partial preservation of the posterior portion above the calcarine fissure on the left side led to the lack of central visual field disturbance below the horizontal meridian on the right side in this patient. Visual Field Defects and Occipital Lobe Lesions
The occurrence of central homonymous hemianopia alone caused by occipital lesions is a relatively rare symptom. It is known that lesions of the occipital tip produce central visual field disturbance [7–11]. The occipital tip was involved in 6 patients who had central homonymous hemianopia or quadrantanopia. This result was consistent with previous reports that showed an association between occipital tip lesion and central visual field disturbance [7–11], although in 1 patient bilateral lesions were accompanied by slight peripheral visual field disturbance. In a comparison between central visual field disturbance caused by medial area lesions and that caused by occipital tip lesions, complete central homonymous hemianopia or quadrantanopia was marked in patients with occipital tip lesions. On the other hand, central visual field disturbance attributable to the posterior portion of the medial area tended to be incomplete homonymous hemianopia. This result indicated that the fibers related to the central visual field are sparse in the posterior portion of the medial area in contrast to the occipital tip. Our study showed that central homonymous hemianopia was caused by lesions in the posterior portion of the medial area and the occipital tip. This result indicated that central visual field disturbance following the same pattern was caused by lesions in two regions. Based on this indication, it was possible to hypothesize that the fibers related to the central visual field projected to the posterior portion of the medial area, and then approached the occipital tip. However, it is necessary in the future to study the precise pathway of the fibers related to the central visual field in the striate cortex. In conclusion, central visual field disturbance was induced by lesions in the posterior portion of the medial area as well as occipital tip lesions in our study, as reported in previous studies [3–6]. Central visual field disturbances caused by lesions in the posterior portion of the medial area tended to be incomplete homonymous hemianopia, while complete homonymous hemianopia or quadrantanopia occurred due to occipital tip lesions. This result indicates that the concentration of fibers related to the central visual field is sparser in the medial area than in the occipital tip.
Disclosure Statement We declare that we have no conflicts of interest.
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
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Discussion
References
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5 Horton JC, Hoyt WF: The representation of the visual field in human striate cortex: a revision of the classic Holmes map. Arch Ophthalmol 1991;109:816–824. 6 Gray LG, Galetta SL, Siegal T, Schatz NJ: The central visual field in homonymous hemianopia. Arch Neurol 1997;54:312–317. 7 Halpern JI, Sedler RR: Traumatic bilateral homonymous hemianopic scotomas. Ann Ophthalmol 1980;12:1022–1026. 8 Bender MB, Furlow LT: Visual disturbances produced by bilateral lesions of the occipital lobes with central scotomas. Arch Neurol Psychiatry 1945;53:165–170.
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
9 Symonds C, Mackenzie I: Bilateral loss of vision from cerebral infarction. Brain 1957; 80: 415–455. 10 Nepple EW, Appen RE, Sackett JF: Bilateral homonymous hemianopia. Am J Ophthalmol 1978;86:536–543. 11 McAuley DL, Russell RWR: Correlation of CAT scan and visual field defects in vascular lesions of the posterior visual pathways. J Neurol Neurosurg Psychiatry 1979; 42: 298–311.
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1 Horton JC, Hoyt WF: Quadrantic visual field defects: a hallmark of lesions in extrastriate (V2/V3) cortex. Brain 1991;114:1703–1718. 2 Holmes G: The organization of the visual cortex in man. Proc R Soc Lond Series B (Biol) 1945;132:348–361. 3 McFadzean R, Brosnahan D, Hadley D, Mutlukan E: Representation of the visual field in the occipital striate cortex. Br J Ophthalmol 1994;78:185–190. 4 Wong AMF, Sharpe JA: Representation of the visual field in the human occipital cortex. Arch Ophthalmol 1999;117:208–217.
Received: September 9, 2013 Accepted: October 10, 2013 Published online: January 16, 2014
Clinical Study of the Visual Field Defects Caused by Occipital Lobe Lesions Katsuhiko Ogawa a Hiroshi Ishikawa b Yutaka Suzuki a Minoru Oishi a Satoshi Kamei a a
Division of Neurology, Department of Medicine, and b Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Tokyo, Japan
Abstract Background: The central visual field is projected to the region from the occipital tip to the posterior portion of the medial area in the striate cortex. However, central visual field disturbances have not been compared with the location of the lesions in the striate cortex. Methods: Thirteen patients with visual field defects caused by partial involvement of the striate cortex were enrolled. The lesions were classified according to their location into the anterior portion, the posterior portion of the medial area, and the occipital tip. Visual field defects were examined by the Goldmann perimetry, the Humphrey perimetry and the auto-plot tangent screen. We defined a defect within the central 10° of vision as a central visual field disturbance. The visual field defects in 13 patients were compared with the location of their lesions in the striate cortex. Results: The medial area was involved in 7 patients with no involvement of the occipital tip. In 2 of them, peripheral homonymous hemianopia without central visual field disturbance was shown, and their lesions were located only in the anterior portion. One patient with a lesion in the posterior portion alone showed incomplete central homonymous hemianopia. Three of 4 patients with lesions located in both the anterior and posterior portions of the medial area showed incomplete central homonymous hemianopia and
© 2014 S. Karger AG, Basel 1015–9770/14/0372–0102$39.50/0 E-Mail [email protected] www.karger.com/ced
peripheral homonymous hemianopia. The occipital tip was involved in 6 patients. Five of them had small lesions in the occipital tip alone and showed complete central homonymous hemianopia or quadrantanopia. The other patient with a lesion in the lateral posterior portion and bilateral occipital tip lesions showed bilateral slight peripheral visual field disturbance in addition to complete central homonymous hemianopia on both sides. Conclusions: Lesions in the posterior portion of the medial area as well as the occipital tip caused central visual field disturbance in our study, as indicated in previous reports. Central homonymous hemianopia tended to be incomplete in patients with lesions in the posterior portion in the medial area. In contrast, complete central homonymous hemianopia and quadrantanopia were shown in patients with occipital tip lesions. Our study suggested that the fibers related to the central visual field were sparse in the posterior portion of the medial area in contrast to the occipital tip, and approached the occipital tip with a high concentration of fibers. © 2014 S. Karger AG, Basel
Introduction
Visual field defects due to lesions of the occipital lobe are usually attributed to damage to the striate cortex [1]. The map presented by Holmes [2] was widely adopted as a detailed representation of the visual field in the human Katsuhiko Ogawa, MD Division of Neurology, Department of Medicine Nihon University School of Medicine 30-1 Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610 (Japan) E-Mail ogawa.katsuhiko @ nihon-u.ac.jp
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Key Words Central visual field · Occipital tip · Striate cortex
inappropriate for the comparison between visual field defects and the locations of lesions in the striate cortex. The locations of occipital lobe lesions were evaluated with computed tomography and magnetic resonance imaging (MRI). The time between the onset of initial symptoms and the radiological study ranged from 14 h to 7 days. The locations of lesions in the striate cortex were classified into the occipital tip and the medial area (fig. 1). Lesions in the medial area were subdivided into anterior and posterior portions in an axial position (fig. 1). Visual field defects were evaluated with Goldmann perimetry, Humphrey perimetry and auto-plot tangent screen. The area of visual field defects was grouped into central and peripheral visual fields. A visual field defect within the central 10° was regarded as a central visual field disturbance. A visual field defect peripheral to the central visual field was regarded as a peripheral visual field disturbance.
Thirteen patients aged 24–84 years (male: 11 patients, female: 2 patients) were enrolled in this study. They were admitted to our hospital from 1985 to 2012 because of visual field defects caused by lesions in the occipital lobe. Occipital lobe lesions in the 13 patients showed partial involvement of the region from the occipital tip to the medial area in the striate cortex. Patients with lesions involving the whole striate cortex and lesions outside the occipital lobe were excluded from this study, because these patients were
Location of Lesions in 13 Patients (table 1) Occipital lobe lesions were identified with computed tomography in 4 patients (patients 3, 7–9) and MRI in the other 9 patients (patients 1, 2, 4–6, 10–13). The MRI findings were evaluated using diffusion-weighted images in 2 patients (patients 2, 5), fluid-attenuated inversion recovery images in 4 patients (patients 1, 4, 6, 12) and T2weighted images in 3 patients (patients 10, 11, 13). The view of the MRI images was axial in all 13 patients. The diagnosis of the occipital lobe lesions was cerebral hemorrhage caused by arteriovenous malformation in 1 patient (patient 7) and brain infarction in the other 12 patients. The lesions of 7 patients (patients 1–7) were located in the medial area in the striate cortex with no occipital tip lesions. In these 7 patients, the lesions were located on one side in 6 patients (patients 1–5, 7). In 1 patient (patient 6), the lesions below the calcarine fissure were located on both sides, while the lesion above the calcarine fissure was located on the left side. Lesions were located in the anterior portion of the medial area in 2 patients (patients 1, 2). In 4 patients (patients 3–6) the lesions involved both the anterior and posterior portions. The lesion of 1 patient (patient 7) was located in the posterior portion of the medial area. On the other hand, the occipital tip was involved in 6 patients (patients 8–13). In these 6 patients, the lesions of the occipital tip were located on one side in 5 patients (patients 8, 9, 11–13) and on both sides in 1 patient (patient 10). The lesions in 5 patients (patients 8, 9, 11–13) involved the occipital tip alone. In 1 patient (patient 10), the lesion on the right side extended to the posterior portion of the medial area from the occipital tip, while the lesion on the left side was located only in the occipital tip.
Visual Field Defects and Occipital Lobe Lesions
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
Fig. 1. Schema of the striate cortex. The medial area (brown) of the
striate cortex is divided into the anterior and posterior portions. The occipital tip (pink area) is located at the pole of the occipital lobe.
striate cortex [3, 4]. On this map, the central visual field was represented at the occipital tip, while the peripheral visual field was mapped anteriorly. In recent years, Horton and Hoyt [1] pointed out the underestimation of the cortical magnification of the central visual field in humans. Other recent studies also reported that the area corresponding to the central visual field expanded to the medial area in the striate cortex [3–6]. However, a comparison between the central visual field disturbances due to lesions of the occipital tip and those due to the medial area in the striate cortex has not been reported. In this study, we studied the characteristics of central visual field disturbances caused by lesions in the striate cortex, based on the investigation of the correlation between visual field defects and the location of lesions in the striate cortex.
Patients and Methods
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Results
Table 1. Breakdown of 13 patients with visual field defects caused by occipital lobe lesions
No./ age/sex
Localization of the lesion side
medial area
Central visual field disturbance (≤10°)
Peripheral visual field disturbance (>10°)
Temporal crescent
− − + (lt. incomplete hom. hemianopia) + (lt. incomplete hom. hemianopia) + (lt. incomplete hom. hemianopia) + (bil. complete superior altitudinal hemianopia) + (lt. incomplete hom. hemianopia) + (lt. complete superior hom. quadrant–anopia) + (lt. complete hom. hemianopia) + (bil. complete hom. hemianopia)
+ (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (lt. hom. hemianopia) + (BSAH, rt. inferior hom. quadrantanopia) − −
− − − + (lt. eye) + (lt. eye) −
− + (bil. slight)
− −
− −
− −
−
−
tip
anterior posterior portion portion 1/61/F 2/66/M 3/84/M 4/67/F 5/66/M 6/63/M
rt. rt. rt. rt. rt. bil. rt. lt. rt. rt.
+ + + + + + + − −
− − + + + + + + −
− − − − − − − − +
9/53/M rt. 10/45/M bil. rt. lt. 11/62/M lt. 12/58/M lt.
− − − − −
− + − − −
+ + + + +
13/70/M rt.
−
−
+
7/24/M 8/78/M
+ (rt. complete hom. hemianopia) + (rt. complete superior hom. quadrant–anopia) + (lt. complete hom. hemianopia)
− −
Analysis of Visual Field Defects (fig. 2) Disturbance of the visual field was measured with Goldmann perimetry in 11 patients (patients 1–6, 9–13), auto-plot tangent screen in 1 patient (patient 7) and Humphrey perimetry in 1 patient (patient 8).
their visual field defects spread to both the upper vertical meridian and the horizontal meridian. The central visual field disturbance in patient 6 spread to the bilateral horizontal meridians and was bilateral complete superior altitudinal hemianopia.
Central Visual Field Disturbance in 13 Patients (table 1, fig. 2) Central visual field disturbance occurred in 11 patients (patients 3–13). Seven (patients 3–5, 7, 9, 11, 13) showed central homonymous hemianopia on one side. One patient (patient 10) showed central homonymous hemianopia on both sides. Central homonymous hemianopia did not reach the lower vertical meridian in 1 patient (patient 3) and both the upper and lower vertical meridians in 3 patients (patients 4, 5, 7). Accordingly, these 4 patients (patients 3–5, 7) showed incomplete central homonymous hemianopia. In contrast, 4 patients (patients 9–11, 13) showed complete central homonymous hemianopia because their central homonymous hemianopia reached both the upper and lower vertical meridians. Central visual field disturbance in 2 patients (patients 8, 12) was complete central homonymous quadrantanopia because
Disturbance of the Peripheral Visual Field in 13 Patients (table 1, fig. 2) Peripheral visual field disturbance occurred in 7 patients (patients 1–6, 10). Two patients (patients 1, 2) showed peripheral visual field disturbance alone. In the remaining 5 patients (patients 3–6, 10) peripheral visual field disturbance was accompanied by central visual field disturbance. In 5 patients (patients 1–5), peripheral homonymous hemianopia occurred on one side. Goldmann perimetry in patient 10 showed bilateral homonymous hemianopic central scotomas with vertical steps and peripheral visual field disturbance observed almost within 20° on both sides. The peripheral visual field disturbance in 1 patient (patient 6) showed bilateral superior altitudinal hemianopia in addition to inferior homonymous quadrantanopia on the right side. In addition a temporal crescent was present on the contralateral eye in 2 patients (patients 4, 5).
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rt. = Right; lt. = left; bil. = bilateral; hom. = homonymous; BSAH = bilateral superior altitudinal hemianopia.
No.
MRI/CT findings
Visual field defects
1
Rt
Lt
Rt
Lt
Rt
2
Rt 3
Rt
Lt
Rt
4
Rt
Lt
Rt
5
Rt
Lt
Rt
6
Rt Lt
Rt
Rt
(For fig. 2 (patients 7–13) see next page.)
Visual Field Defects and Occipital Lobe Lesions
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
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Fig. 2. Radiological findings and visual field defects in 13 patients.
7
Rt
Lt
Rt
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The Holmes’ [2] map provided the most detailed representation of the visual field in the human striate cortex [5]. However, recent studies pointed out an expansion of the area corresponding to central vision in the posterior part of the striate cortex [3–6]. Horton and Hoyt [5] indicated the underestimation of the cortical magnification of central vision in the Holmes’ [2] map. They reported that the area corresponding to the central visual field within 10° amounted to about 50% of the striate cortex, based on the correlation between the localizations of striate cortex lesions imaged by MRI and visual field defects in humans [5]. According to a study by Wong and Sharpe [4], 37% of the total surface area of the medial occipital cortex corresponded to the central 15° of vision. McFadzean et al. [3] reported that the central 10° of the visual field occupied at least 50–60% of the striate cortex. These three studies suggested that the central visual field corresponds to the posterior half of the medial area in the striate cortex, and the peripheral visual field corresponds to the anterior half [3–5]. In our study, lesions in 7 patients were located in the medial area in the striate cortex, with no occipital tip lesions. Among them, 3 patients with involvement of the anterior and posterior portions of the medial area showed both peripheral homonymous hemianopia and central homonymous hemianopia. On the other hand, peripheral homonymous hemianopia without central visual field disturbance occurred in 2 patients only with a lesion in the anterior portion of the medial area. One patient with a lesion in the posterior portion of the medial area showed central homonymous hemianopia without peripheral visual field disturbance. These results suggested that the responsible lesion for central visual field disturbance extended to the posterior portion of the medial area in the striate cortex, which was consistent with recent studies that reported the responsible lesion for central visual field disturbance [3–6]. Bilateral superior altitudinal hemianopia in 1 patient correlated well with the bilateral involvement of the anterior and posterior portions of the medial area below the calcarine fissure. A lesion above the calcarine fissure on the left side caused right peripheral inferior homonymous quadrantanopia, and this lesion was located slightly more anterior than the location of the lesions below the calcarine fissure. This result might indicate that partial preservation of the posterior portion above the calcarine fissure on the left side led to the lack of central visual field disturbance below the horizontal meridian on the right side in this patient. Visual Field Defects and Occipital Lobe Lesions
The occurrence of central homonymous hemianopia alone caused by occipital lesions is a relatively rare symptom. It is known that lesions of the occipital tip produce central visual field disturbance [7–11]. The occipital tip was involved in 6 patients who had central homonymous hemianopia or quadrantanopia. This result was consistent with previous reports that showed an association between occipital tip lesion and central visual field disturbance [7–11], although in 1 patient bilateral lesions were accompanied by slight peripheral visual field disturbance. In a comparison between central visual field disturbance caused by medial area lesions and that caused by occipital tip lesions, complete central homonymous hemianopia or quadrantanopia was marked in patients with occipital tip lesions. On the other hand, central visual field disturbance attributable to the posterior portion of the medial area tended to be incomplete homonymous hemianopia. This result indicated that the fibers related to the central visual field are sparse in the posterior portion of the medial area in contrast to the occipital tip. Our study showed that central homonymous hemianopia was caused by lesions in the posterior portion of the medial area and the occipital tip. This result indicated that central visual field disturbance following the same pattern was caused by lesions in two regions. Based on this indication, it was possible to hypothesize that the fibers related to the central visual field projected to the posterior portion of the medial area, and then approached the occipital tip. However, it is necessary in the future to study the precise pathway of the fibers related to the central visual field in the striate cortex. In conclusion, central visual field disturbance was induced by lesions in the posterior portion of the medial area as well as occipital tip lesions in our study, as reported in previous studies [3–6]. Central visual field disturbances caused by lesions in the posterior portion of the medial area tended to be incomplete homonymous hemianopia, while complete homonymous hemianopia or quadrantanopia occurred due to occipital tip lesions. This result indicates that the concentration of fibers related to the central visual field is sparser in the medial area than in the occipital tip.
Disclosure Statement We declare that we have no conflicts of interest.
Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
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Cerebrovasc Dis 2014;37:102–108 DOI: 10.1159/000356848
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1 Horton JC, Hoyt WF: Quadrantic visual field defects: a hallmark of lesions in extrastriate (V2/V3) cortex. Brain 1991;114:1703–1718. 2 Holmes G: The organization of the visual cortex in man. Proc R Soc Lond Series B (Biol) 1945;132:348–361. 3 McFadzean R, Brosnahan D, Hadley D, Mutlukan E: Representation of the visual field in the occipital striate cortex. Br J Ophthalmol 1994;78:185–190. 4 Wong AMF, Sharpe JA: Representation of the visual field in the human occipital cortex. Arch Ophthalmol 1999;117:208–217.
