 Yeah What I mean by this It's like this is We can go ahead and get started so I need the microphone You want to join then I'm gonna have you guys kind of pair up So hopefully you guys were able to watch the video and review the visual field anatomy So I'm not really gonna go over specifics of the anatomy Here's your chance if you didn't Or really technical aspects of Humphreys and Colomons and things like that But if you have any questions Ask me and I'll do my best. I don't really answer. I'll get back to you later So here's a normal goldman visual field these are normal blind spots for those not familiar with visual fields It's like you're looking out of the page as the patient and so what's on the right side is from the patient's right eye What's on the left is from the patient's left eye? These are the normal physiologic blind spots, which are around 15 degrees temporally of the point of fixation and normal fully All visual fields is about 60 degrees superior nasally 60 to 7 inferiorly Around 90 or so temporarily that would be a full visual field Teresa so we're kind of pairing up twos and threes if you want to join Maybe Rachel over here or whoever you want. It's fine Or if you want to Do all it on your own that's great to you Or you guys can make a group of twos either way So let's start with some cases. So this is Someone sends you this visual field. This is all you know about the patient What kind of things are going through your mind when you see this visual field all we have is this one Which is the left eye So you guys kind of talk amongst yourself Kind of come up with a clinical scenario for this what might be causing it. What else do you want to know about this patient? Brad and Chris kind of give us some thoughts on this so we said like it could be Partial arc you at defect or like a Seco central So we would want to know Like the age of the patient for sure Okay, I mean obviously any like ocular history do they have a known diagnosis of Very important never I might be helpful So let's say this is a 30 year old And let's say this is the right eye is normal. What's kind of your differential at that point? The right eye is completely right as normal 30 year olds So, you know 30 year old girl someone sends you this visual field. What are top five things that you're wondering? What things you might think are abnormal I know so things like eye pain color vision loss Things like that. So Let's say it's someone with in this is in both eyes What they what's your differential for our seco central scutomas in both eyes? Let's say painless You like systemic diseases Yeah So by a lot of optic neuritis Painless or seco central scutomas are concerning for nutritional deficiencies. So B12 types of C's Like if they and be tall things that give Optic neuropathies from medications Vibers saw in the differential for bilateral seco central scutomas so Lot of times we get really poor records from outside and we get things like this But this even just this alone gives us a lot of information that gives us a list of questions that we want to answer when we see the patient So this is kind of what gives a seco central scutoma. So it's from Disorder of the papillomaculobungal, which is right here The fibers coming right from the center of the phobia over to the optic disc. These are very Nutrient dense areas. So this is why things like nutritional deficiencies particularly affect this area and optic neuritis often gives us central scutoma Extending over to be a seco central scutoma again because they're very active Areas that are easily injured with oxidative stress So this is the example of a seco central scutoma So here's the case 19 year old man painless loss of vision left eye progressed over three days Three weeks later had no improvement in that eye, but then developed painless loss in the right eye So you guys talk kind of what's top on your differential on this case? I haven't really given you guys too many details, but Young guy otherwise healthy loses vision one eye painless Then not too long later. There's this vision the right eye still painless. How about you guys over here? Any thoughts on that? I have a knee jerk reaction to what you might be thinking first Here's his exam right eyes count fingers 24 in the left. No color. There's no APD. I movements are full You look at his fund is he has some peri-pepillary tilting ectasia We're hearing optic nerves and includes at this point these prizes and have APD because Yeah The so that keep that in mind and we'll talk about that in this case It's not surprising because it's bilateral, but Once we go over what it actually is reminding them Anyone else have any thoughts or diagnosis at this point Leavers. Yep. So young guy painless vision loss sequential rapidly sequential The other clues are the peri-pepillary tilting ectasia So the nerve can look pretty normal and kind of a full appearance, but you look around the nerve It's got these little tilting ectasias, but it's more of a pseudo-ladema appearance than regular than actual optic disc edema So what's the typical visual field visual field and leavers and I already talked about it So bilateral secocentral scatomas is most classic for leavers So this is what the patient had So going back to leavers. So initially when they present in one eye So if you had seen the sky when you just Had the problem in the whichever the first eye was and you didn't see a APD that would be very confusing because he was count fingers No color vision that I you're very concerned for optic neuropathy, but you don't see an APD So that's very confusing. You might think it's a retina problem. You might think he's faking which can happen, but It's for reasons. I don't think anyone really knows Possibly because the other eye is going to be affected. It's kind of in that pre-monitory phase But you don't see an APD and it's not unusual to not see an APD with that first eye that's involved Either it doesn't involve the ganglion cells in the back that contribute more to the APD or it's because that other eye is subclinically involved enough to not Allow for an APD So always keep the evers in mind when you see something. It looks like a bad optic neuropathy, but you're not seeing an APD Don't discount leavers in that situation, especially if it's like the classic young man with leavers Or with payments vision loss So someone how is the evers inherited? What is the genetic disorder for leavers? There's about three classic genetic mutations for it, but there's others being discovered Some mitochondrial leavers may not have APD initially Most commonly is going to eventually be bilateral after usually a couple of months in between their eyes Seco central scatoma. Here's another case so this guy So pay attention to these things so you get these visual fields which look terrible except for some sparing, but he has 2020 vision So what do you think is going on with this lesion this visual field? You know to see as a foveal thresholds are 30 on the left 39 on the right which goes with this 2020 vision What a theory I do that even if it was robust so your retinal artery probably would end up with 20 20 vision So so you kind of label it as constriction was sparing the macula. So where would you localize that you also already mentioned the retina can cause that Bilateral optic neuropathy is probably less likely so Retina or bilateral cortical like you mentioned are probably two most common so this guy is actually he was I don't know. He's about 40. He was Very sad story was hanging a flag up at a restaurant on Veterans Day like a year ago and fell off the ladder and Had a hemorrhage in the back of his head Went to the hospital had that treated and eventually Decompensated and was herniating and stroked out his bilateral PCA's while herniating stroked out his bilateral oxyprolubes So this is what he had he also became deaf at the time also, so doing a good deed and became Helen Keller, but So you see going back to the visual field. It's a little bit Not as bad in the left in both eyes if you look closely at his MRI it's Not as bad on the right, but this is a bilateral oxyprolation You can see it's sparing the tip of the oxyprolobes for the most part, which is why he has really good central vision So just to kind of briefly review so the oxyprolobes the most posterior part of the oxyprolobes is your macula central vision more anterior and the oxyprolobes is the peripheral vision so if you spare The poles of the oxyprolobes. You have the potential to spare your macula or your central vision Which is what he did which is among all the bad things one of the better things that happened to him You can see this is the contusion from this fall The vision loss is all from back here So here's just a cat scan cat scans are not quite as easy except for maybe our neurologist To read what do you think the visual field will be in this patient? Maybe let's go with our group with a neurologist in it See what what's wrong with the brain in this cat scan is it normal or is it animal? Which side is that normal Over here So actually this is the abnormal size see this dark so strobes that are Subacute to chronic appeared dark on cat scan for all you all the moment is out there So this side is normal, but you see this And hypodensities Terminal the terminology for it. That's Subacute to acute Chronic stroke so acute strokes first 24 hours look normal on cat scan So this one's a little bit tougher because MRIs are much easier to show things like this But I didn't have one on this patient, but so where are we in the brain? So this is the abnormal side Roughly, where are we? It's hard to on this let's say is the inferior occipital low where we are what is the visual field defect with that? so Left occipital because it's the right superior But this was her visual field so Right superior quadren's no pia monomous quadrant no pia From the left inferior occipital infarct So here's the case 27 year old woman. She's five and a half weeks pregnant Brad, you know this patient came with vision loss in both eyes One week and a headache What are you concerned about right now? What are you really concerned about and a pregnant lady with a headache acute onset? That's a good one. Yeah Venus sinus thrombosis So hypercretic will stay Had a pregnant lady So this is her exam 2020 vision has no APD probably is normal sounds fine, right? What else do you want to know for her? I mean, I would want to get a visual field on her You want to know what her nerves look like You know just send her home right now complaining lady These are nerves What's her visual field? potentially going to look like So first what's going on for all the non-optimologists in the room with her nerves a little touch at discotema So severe optic discotema both eyes So you guys talk what's the visual field defects most commonly with optic discotema from papillodema Common visual defects in papillodema That's usually the first thing to see what else so most mild with papillodema is no visual field change Blind spots are one of the first things we see These old depression is a very common one and then Then it starts to get constricted So these people often won't notice that they're losing vision because their acuity is 2020 until their fields get so constricted. So just relying on the subjective Nature the patient's vision is not great. You have to actually go check the visual fields formally if possible So I saw this lady in clinic and these were her visual fields She was pregnant So this isn't really an age talk, but we'll kind of go over a little bit. So she's pregnant. She's got these visual fields So you're worried or you're not worried about this patient. She's got severe papillodema I'll tell you she didn't have a venous science thrombosis. So she just has elevated pressure for no other reason Those with more experience with IH. What are you kind of? Thinking is your next step in this at this point. So again, not an age talk But this is vision-threatening IH that you have to do something more aggressive like lumbar drains possibly Finistrations if needed so She already had her MRI which is normal. Otherwise, opening pressure is 56. It's very high. Otherwise, he's that was normal So she was admitted for a lumbar drain to kind of temporize things drain the fluid repeat visual fields We started die-maps at the same time And then the plan was if visual fields didn't improve then do optinertiae finistrations So this is kind of a gradual progression of her visual fields. So first time I saw her left eye and right eye This is after lumbar drain or this is five days later And so you see improvement there improvement in the right eye So we kind of stuck with things with the diamox. She continued to improve About two months after I first saw her so luckily luckily for her she did okay with diamox so Always keep in mind vision-threatening IH that they have severe Visual field loss Then that's something to be concerned about and you want to be more aggressive of that with lumbar drains possibly optic Nerf teeth and illustrations things like that So just to review fields and IH so we're with papillodema in large blind spots nasal depression Diffuse constriction last thing that goes is the visual acuity Question about that doctor's seat. So this might be wrong too But there's a question that I just had that said what's the most common visual field defects seen in IIH They answer as partial arc you it With or without enlarge blind spot and then enlarge blind spot being the second most common Is that true experience? I feel like a large blind spot is most common, right? They'll make any sense What's the question from? I mean it says that it was I haven't looked up the study honestly, but it says this was what was reported in the IIH Treatment trials, so I don't know. I just didn't know I've never heard of that before Yeah, I don't know the board Collection answer to that in the experience is some large blind spot But but you see those are And that I see the nasal depression a lot also It's controversial depends on the center usually you can This Some people will do contrast some people won't and a pregnant ladies there's with the gadolinium think iodine is contraindicated, but There's no 100% contraindication to get though She was five and a half weeks pregnant on september 5th Because she was really worried I think about the acidosol yeah someone that recommended her diamox, which is Doesn't have great evidence that it's harmful to the baby, but there's In animals it's potentially harmful, but there's no real human evidence that is harmful. So some People are hesitant to take it, but she's been on two grams in september Her ob-gyn is fine with it. Most people are generally fine with it It's just kind of educating the patient that we don't have great evidence one way or the other, but A lot of cases are reported where there's no effect from diamox So here's the 33 year old woman had trouble finding birds in the sky Reading first parts of words seeing the mouse on the computer screen Slowly progressive. She doesn't really know when it started, but it's probably been a few years Things both eyes equally affected otherwise healthy. No family history of diamox So her exam so you can get to 2020 both eyes kind of eccentric vision Colors decrease both eyes People's equal. They're questionably a trace right APT eye movements otherwise normal So these are her optic nerves Anyone quickly want to say what they see with these optic nerves Disc margins look pretty crisp She has a normal cup-to-disk ratio if anything her Optic nerves appear slightly hyperemic But I don't see any optic disc power or disc margins. They look fairly healthy to me Exciting no answers yet for her vision So can you predict the visual field just based on her history? How do you guys kind of discuss what you think her visual field is going to be? Somewhere in the center Just having trouble finding little things So this was her Humphrey So you can see up here. That's can't I tell but down here you see the central lesion here central here Is it possibly more on the left side? So I got these little central scatomas to localize that can you go back to the visual field? Or sorry the golden trees that your group Localize bilateral central scatomas You said right side Yeah, but it'd be bilateral it's bilateral central scatomas Optic nerve could be possible too bilateral optic neuropathies can give you a central scatomas So OCT, RNFL is pretty normal So this is our OCT of the macula on ophthalmologist. This is through the phobia. This is a normal phobia old depression Any of you ophthalmologists want to say what you see on this? What's the uh The left side zone Right in the center So this is correspond with her visual field defects here Yep So she's got a retinal problem causing bilateral central scatomas. So she went to Dr. Bernstein ERG was actually normal that he's concerned for a cone dystrophy in her She's getting genetic testing So The neuro entomologist see right to things too Here's the case 15 year old girl was in a car accident a month prior to me seeing her Her complaints in her vision were just blurry vision at distance and double vision at near had headaches nauseas and neck pain Went to another eye doctor which told she had peripheral vision loss So if you Take out that last sentence that kind of sounds typical of a post concussion patient blurry vision Especially double vision at New York because they get conversions and sufficiency But since this is a visual field lecture Why am I she has some peripheral vision loss after a car accident? Is that A minor car accident. Is that normal or Is that surprising? Yeah, you wouldn't really expect A minor car accident is probably not going to cause peripheral vision loss Maybe if there was head trauma, there's a optic neuropathies, but it wasn't really any head trauma So vision is 2020 color is full people's are normal. I move into normal And had some conversions and sufficiency Consistent with post concussion syndrome These were her optic or her fundus photos Which these are her visual fields So What do you guys think about these visual fields? How would you approach this patient at this point? Given these visual fields She I mean her main complaints were blurry vision at distance double at near it wasn't I can't see anymore I think a 15 year old girl who underwent a traumatic event. You always have to keep in mind functional vision loss So tell me about the tangent screen, what do you do with that? So when they move back you expect the field to expand It stays the same sometimes it gets smaller than that's highly suspicious for non-physiologic vision loss When you get a gold mine, you could do a gold mine too is another option And her gold mine is also concerning So she so 15 year old I was highly suspicious for non-physiologic I did a tangent screen on her sometimes she expanded sometimes she didn't Um, it's hard to really label people as non-physiologic though is post traumatic 15 year old girl I was thinking she was going to be normal But I got a erg which was abnormal And again went to dr. Bernstein And certainly she has right now is pigmentosa so One of the things that looking back made me Should have made me more Or less likely to think it was non-physiologic. She wasn't complaining of vision loss This was just incidentally found She was didn't come in saying I can't see it was just double vision at ear blurry vision And she's had this forever most likely so she's never really known any difference So it wasn't until more questioning that they kind of found out that our night vision was not that great and things like that but So always I really hate non-physiologic disorders because you get stuff like this when it's totally real when it looks Otherwise not So you have to be really careful before you label someone non-physiologic Or I forget so I forgot to make a quiz I'm going to make a quiz and email it to you guys So if you guys can just write your Email address and I'll email it later Now we just have some kind of rapid fire visual fields So I'll show you ones discuss real quick And then someone shout it out Just what the defect is where it localizes List this yeah, so yeah So like they only have the inferiorities. Yeah, so optic Nerve anomaly So it could be bilateral optic nerve problems causing inferior Altitudinal defects Could be brain also so posterior Superior occipital lobe cause that field defect Of this one with the visual field defect Except it it wouldn't be parietal be temporal or inferior occipital So this is just again showing the occipital lobe posterior occipital lobe For the central vision the macula peripheral vision is represented anteriorly. So this is a small So this would be you'd expect this to be more posterior occipital lobe given this small more central Superior quadringtonopia How about this one my central field defect the rights pretty much Not much vision there with a left temporal defect What's the name for that kind of visual field defect? If what's symmetric You don't know if there's a Well, we know that the right eye is severely affected which localizes to Anterior to the chiasm We know that the left eye has a temporal defect which localizes to Junctional scatoma. Yeah, so a junctional scatoma because there's a temporal defect in one eye and a Central defect or kind of diffuse optic neuropathy defect in the other eye So that localizes to the chiasm, but it's involving more of the right optic nerve than it is the left That's why you get so much involvement of the right optic nerve And it extends back to the chiasm and affects those fibers that cross and causes that Temporal defect on the left eye So this localizes to the optic chiasm A little bit more anterior in the right optic nerve though So you think of things like tuotary tumors any optic chiasm lesion How about this one right parietal and right superior occipital Anterior to the chiasm anything It's to kind of done this before but as a repetition So This visual field defect plus a right apd So what's the visual field defect? You know, yeah as a right apd Is that weird? That is functional visual That one more time did everyone hear that? So this localizes to Left optic tract specifically Because So that's exactly right so our temporal fields are bigger than our medial nasal fields So there's an over representation of that temporal visual field. So there's more fibers from that From the medial fibers that cross So the optic tract has an over representation of the contralateral eye So when you take out the optic tract, it's still asymmetrically involving that contralateral eye Which is why you'll get an apd. It's usually not a huge apd. It's small But so if you see a homonymous hemianopia with an apd And you get a little confused don't be confused. It's probably an optic tract lesion Let this one So these are actually large blind spots the temporal layer which localizes to Tell me a few disorders that you're looking for what's the differential diagnosis for an optic chiasm lesion Mariatinomas apoplexy meningiomas What's the vascular one? Neurism This weird thing Actile is very uh, this is a geniculate lesion So lesion of the lateral geniculate nucleus that the thalamus can give these very strange looking homonymous hemianobias Junctionals ketomas you have a central scatoma on the right left eye Superior temporal so it's catching those medial fibers that are coming. So it's pushing up from the bottom to the chiasm So the lesion is on the left side. It's at the chiasm involving more of the left side more of the More of the optic nerve on the left side more of just the crossing fibers from the right oxidol on the so this is Sparing temporally in the left side So you have a otherwise a left monomous hemianopia. So this localizes to the right occipital the more interior But not totally interior because it's sparing some there How about this make of the clinical scenario for this dial is like like clover leaf like so lazy patient With something going on in the right eye So I made these I was pretty proud of this So relief isn't perfect either, but it's not too bad Any questions that's all I've got for you today