Visual field diagnosis
by pattern matching

It goes without saying that the cause of a visual field defect is best analyzed by combining technical perimetric expertise with detailed knowledge of the anatomy of the visual pathways and their vascular supplies, of neurophysiology, of neuropathology, and, of course, of the patient's history and full clinical picture. Pattern matching may serve as a provisional shortcut. Commonly occurring patterns are presented in a schematic fashion below. Just look for a near match and point the cursor to the pattern to open a brief verbal description.

To keep the number of figures within reasonable limits, both fine details and different severities of damage have to be sacrificed. Hence, there are only two levels of severity (absolute [=no vision] and relative) and two types of borders (steep and sloping). Absolute defects are rendered in solid black and relative defects in gray. All focal lesions are assumed to be situated on the right-hand side.

Technical detail on visual field examinations is presented elsewhere on this site. Overviews of the fiber arrangement within the visual pathways and the topography of the primary visual cortex (V1), and its arterial supplies, can be viewed in a separate window.

Precautionary notes:

• Make sure that the actual examination results are good enough to merit analysis
• Use more than one test distance if functional visual loss may be at play
• Avoid overdoing "congruence/incongruence" and "macular sparing" analyses
• Recall that there are no disease-specific visual field defects

Strictly monocular defects

Funduscopy and fundus imaging are generally more informative than visual field maps with retinal diseases, as exemplified elsewhere on this site.

As to retinal vascular lesions and focal lesions of the retinal nerve fiber layer, these may cause countless variants of visual field defects. Both types of lesions usually present borders running in parallel with the involved vessels or nerve fiber bundles. The borders tend to be steep with vascular lesions and to be sloping with bundle lesions. Here, only the most common variants, arcuate scotomata, are shown.

A central scotoma with sloping borders is most commonly due to macular disease or optic neuritis

A central scotoma with sloping borders and asymmetrical extension is most commonly due to optic nerve compression or optic neuritis

An upper temporal depression or scotoma with sloping borders that spills over the vertical meridian is usually due to a tilted disc

A peri-cecal scotoma is most commonly due to disc swelling or peripapillary choroidal disease, including chorioretinal folds and the big blindspot syndrome; it may also be due to poor fixation

A relative arcuate scotoma with absolute nuclei is usually due to glaucoma, glaucoma, glaucoma, or drusen of the optic nervehead

An absolute arcuate scotoma is usually due to glacoma or a retinal vascular occlusion close by the disc

Absolute double arcuate scotomata are usually associated with a nasal step and are most commonly caused by glaucoma

An arcuate scotoma breaking out to the periphery is usually due to glacoma or a retinal vascular occlusion

A sectorial or altitudinal defect is most commonly seen with anterior ischemic optic neuropathy, traumatic optic neuropathy, and optic nerve hypoplasia

Loss of a temporal crescent is most commonly seen with diseases involving the peripheral retina, the optic nerve sheath, meningeal diseases, and anterior infarction of the contralateral primary visual cortex

A central field island with sloping borders is typical of advanced glaucoma, masses of drusen in the optic nervehead, and chronic-atrophic papilledema

A unilateral central field island with steep borders is strongly suggestive of functional visual loss and particularly so if a relative afferent pupil defect is lacking

Bilateral, nonymous defects

The term "nonymous" is used here to imply that the defect borders stay away from the vertical meridians. Note that bilateral nonymous defects include bilateral instances of monocular defects as exemplified above plus inherently bilateral conditions. Several hereditary, toxic, and malnutritional conditions belong to the latter category, including retinitis pigmentosa, chloroquine and amodiarone side effects, dominant optic atrophy, Leber's hereditary optic neuropathy, and "tobacco-alcohol amblyopia". These normally fairly symmetrical conditions will not be detailed separately. An exception is made for vigabatrin-associated visual loss, because of its unusual peripheral distribution.

Cecocentral scotomata occur with several hereditary, toxic, and deficiency conditions

Ring scotomata are most commonly associated with long-term use of chloroquine and related drugs

Upper temporal depressions or scotomata with sloping borders that spill over the vertical meridians are usually due to tilted discs

Scattered shallow scotomata are commonly seen in inflammatory retinopathies and in multiple sclerosis, even without prior episodes of optic neuritis

Symmetrical peripheral field loss is characteristic of vigabatrin toxicity but is also seen with fatigue. Vigabatrin is used in the treatment of epilepsy

Heteronymous defects

These defects respect the vertical meridians and have different lateralities in the two eyes. The most common are those associated with compression and/or deformation of the median chiasm. Their clinical importance motivates illustration of several degrees of severity. Note that real mid-chiasmal lesions rarely are perfectly symmetrical and that antero-lateral lesions do not present bitemporal defects. Postero-lateral chiasmal lesions present homonymous defects.

Shallow upper temporal depressions are the earliest signs of midchiasmal involvement

Temporal hemifield depressions, more pronounced above, with moderate midchiasmal involvement

Relative defects in 3 quadrants with more severe midchiasmal involvement. Note gradual transition between upper temporal and lower nasal quadrants.

Upper temporal quadrantanopsia with a gradient all the way around fixation to the upper nasal quadrant, with severe midchiasmal involvement

Bitemporal hemianopsia plus, with some remaining function in upper nasal quadrants only. Very severe chiasmal involvement, with a median preponderance

Lateral chiasmal syndrome (also known as anterior knee or von Willebrand syndrome), with an ipsilateral central scotoma and a contralateral temporal depression

Truly binasal visual field defects are almost unheard of and are suggestive of functional visual loss

Homonymous defects

These defects respect the vertical meridians and have the same laterality in both eyes.

Relative quadrantic depressions may have the cause located anywhere between the posterior chiasm and the primary visual cortex, but the most common location is the anterior temporal lobe. Sloping borders are suggestive of compression or infiltration of the visual pathways rather than destruction

Relative hemi-depressions may have the cause located anywhere between the posterior chiasm and the primary visual cortex. Sloping borders are suggestive of compression or infiltration of the visual pathways rather than destruction

An absolute hemianopia may have the cause located anywhere between the posterior chiasm and the primary visual cortex. Steep borders are suggestive of destruction of the visual pathways

An absolute hemi-defect with central sparing is strongly suggestive of an anterior V1 infarct from occlusion of the posterior cerebral artery, with sparing of a middle cerebral artery territory (the posterior pole)

Absolute hemi-central scotomata are strongly suggestive of a posterior V1 infarct from occlusion of a distal branch of the middle cerebral artery

Absolute upper quadrantanopias are suggestive of a partial V1 infarct from occlusion of a branch of the distal posterior cerebral artery. Consider also a lesion of the anterior temporal lobe, for example, following epilepsy surgery

Absolute lower quadrantanopias are suggestive of a partial V1 infarct from occlusion of a branch of the distal posterior cerebral artery

Absolute crescentic defects are strongly suggestive of an anterior V1 infarct from occlusion of a branch of the distal posterior cerebral artery

Absolute hemi-defects with peripheral sparing are strongly suggestive of a posterior V1 infarct from occlusion of the posterior cerebral artery

Upper segment- or sectoranopias are most common with destructive anterior temporal lobe lesions, for example, following epilepsy surgery. Consider also a partial V1 infarct from occlusion of a branch of the distal posterior cerebral artery

Absolute horizontal sectoranopias are characteristic of partial infarcts of the lateral geniculate nucleus (its lateral choroidal artery territory) but may also occur with partial V1 infarcts from occlusion of the distal posterior cerebral artery

Bilateral homonymous defects

Bilateral homonymous hemianopias with left-hand central sparing are strongly suggestive of bilateral V1 infarcts from bilateral occlusions of the posterior cerebral arteries, with sparing of a middle cerebral artery territory on the right

Bilateral homonymous hemianopias with bilateral central sparing are strongly suggestive of bilateral V1 infarcts from bilateral occlusions of the posterior cerebral arteries, with sparing of middle cerebral artery territories on both sides

Bilateral crossed quadrantanopias or "butterfly fields" are strongly suggestive of bilateral V1 infarcts from bilateral occlusions of end branches of the posterior cerebral arteries