JAMA Clinical Challenge: Homonymous Hemianopia With Normal M
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A man in his 80s presented with 3 months of painless progressive vision loss, followed by gait changes, memory loss, and 10-lb unintentional weight loss. Medical history was notable for coronary artery disease, hypothyroidism, and prostate cancer in remission. On ophthalmic examination, visual acuity was handmotionOU (baseline from 9months
prior was 20/50 OD and 20/30 OS), with briskly reactive left pupil and trace right relative afferent pupillary defect. He could detect 2/4 gross colors in the right eye and 1/4 gross colors in the left eye. Confrontation visual fields revealed dense right homonymous hemianopia with additional asymmetric deficits Goldmann perimetry (Figure 1). Extraocular movements were full of gaze-evoked nystagmus. Horizontal vestibulo-ocular reflex, assessed by head impulse testing,was normal.Slit-lamp and dilated fundus examination revealed pseudophakia and mild epiretinal membrane in the right eye and mild nuclear sclerosis in the left eye.

Neurologic examination showed full motor strength, decreased vibration sense and proprioception in the feet, positive Romberg sign, and inability to tandem walk. Mini-Mental State Examination score was 6 of 30.

Magnetic resonance imaging brain and orbits with and without contrast and magnetic resonance angiography head and neck were unremarkable. An electroencephalogram showed no localizing signs. The syphilis screen was negative. Serum thiamine, vitamin B12, and thyrotropin levels were normal. Cerebrospinal fluid composition, infectious studies, cytology, flow cytometry, and paraneoplastic panel showed only mildly elevated protein.

Source: https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2764382