 So, Laura is going to be, is going to be showing us some cases later on in this talk. She said, yeah. And so, I'm just going to talk a little bit about visual field testing. And some of you may have heard this talk before, because, you know, we are on a two-year cycle now, and previously on a three-year cycle. Some of you may have heard the talk before. Some of you, it's all new. So, let's without any further ado. So, what I'm going to talk about is how to do visual field testing, how to record visual field testing, various testing strategies, and testing artifacts in automated perimetry. And so, you all remember the visual system, okay? I'm going to just take that as given. But there are a variety of ways in which you can test the visual system. A lot of people sort of conceive of the visual field as sort of this mountain of vision in a sea of darkness, right? And the point of this mountain is that the vision is not as good in the periphery, and then it gets better and better and better towards the center. And so, this rising peak here indicates better and better and better acuity. And so, what you can do is you can sort of enter into the field of vision with various sizes and brightnesses of objects and expect them to be seen progressively closer towards the center as they get smaller and dimmer, okay? The most common way of field of vision testing is confrontation fields. I prefer confrontation rather than confrontational because I think confrontational implies, can you say this? Okay, so here you are. You're aligning yourself up with a patient's eye. When you're doing count fingers vision, you don't really need to have it carefully aligned with a patient's eye. You can just have them look at your nose and you can keep your eyes open. And then it gives you both hands free. So some people do one or two. Some people do one or two or five fingers of counting. It's important to make sure, and this is something we start off with the medical students, which is coming up on Monday in a couple of weeks, to make sure that the fingers are not aligned like this. How many fingers? I don't know. Is that one or two? I can't tell. So you're testing in all four quadrants, not out here. And we make the point with the medical school, testing somebody in there is teaching the medical students to do the semaphore version of visual field testing, but nobody admits it. So the other way of doing the visual field testing is with some sort of more formal testing method, and they all employ some kind of a bowl representing visual space around the patient. When you're talking about kinetic perimeter, it's a moving target coming in towards the center, and you have a certain specified brightness and size of stimulus that is brought in from the edges, and then you join up those dots representing what they call an ice doctor of visual field. And in static perimeter, you're shining different brightnesses and sizes of objects in various locations, and the brightness is going to be variably detected as you get closer towards the center. So kinetic meaning moving, and static meaning not moving. And so in kinetic perimeter, you get these ice doctors and static perimeter, you just get this sort of graded mountain of vision. We also have the beloved tangent screen. We use that a lot. It is not just a way of decorating the walls. There's one at the VA. There's actually a regular one at the VA somewhere, but that got moved. But the one down in low vision surface is just perfectly fine. As a matter of fact, it's the fanciest one I've ever seen. It's very, very nice. And the nice thing about the tangent screen is, unlike all the other methods with the tangent screen, you can vary the distance of the patient from the screen rather than just the brightness and size of objects. So in recording the field of vision, the right eye goes on the right. The left eye goes on the left. This is the only thing that is different in entire medicine where things are reversed. Everything else is as if the patient is lying on the page and you're looking at them. In the visual field, it's as if the patient has the field and is just kind of burning it. It's like Superman burning it into the page. One of the most successful ways of determining which visual field you're looking at is I but looking at the appearance of the physiologic blind spot. And you want to double check in a Humphrey automated perimetry that where the machine thinks the blind spot is actually where the blind spot is turning up. There's a little gap in the printout where the blind spot is intended to be on a Humphrey visual field. And if it's not turning up where the blind spot is, then you may be looking at a patient being tested on the wrong eye. So moving on to some of the automated perimetries, there are a wide variety. Almost everybody now is going with some form of CETA. Does anybody know what CETA stands for? Threshold Algorithm? Something, something. Algorithm? Threshold Algorithm, Swedish. These are interactive, actually. Not integrative, interactive. And so what's interesting about CETA testing is that basically the machine assumes that a certain visual field exists. And then as the test is being done, that field is being modified and updated during the testing. And so before that, basically, the stimuli were presented at a certain speed and a certain brightness, regardless of what the patient was doing. And with this interactive, the machine does a few preliminary tests and decides how the patient is seeing and how quickly they're responding and adjusts accordingly. And so what that results in is a huge variation in the amount of time that it takes to do a test. So you guys all need to be aware. So full-threshold testing is really nice. But it can take up to 20 minutes per eye, which is agony. That is not a fun thing. So the regular CETA standard, if a patient is doing well, can take five, six minutes per eye, which is way more tolerable. And the CETA fast, which has a commensurate slight decrement in information, is usually five minutes and under. So you can really speed up the situation by changing your algorithm. So of course, neuroephthalmologists never trust anything. But somebody's done some testing and comparing CETA to golden visual fields. Because we were all raised on golden visual fields. Goldmans are preferred by the patients, I think mostly because you can chit-chat with the examiner while you're doing it. You cannot do that during a CETA test. You have to really maintain your attention. But on the other hand, having a little chit-chat can help to keep you awake. So it's not an unreasonable thing when a patient is a child or an elderly person or somebody's had a stroke or falling asleep to switch to a Goldman because of that chattiness. CETA is way faster. It's much more sensitive. It's CETA is at least as good as a full-threshold. So the testing has been done. It's pretty good for picking up defects. And they concluded that it was a useful alternative. I just wanted to mention some of the variants. And I've heard that this kinetic fixation is actually going to happen. Basically, all of the other tests, there is a central fixation target and the spots appear around it. In this kinetic fixation perimetry, the fixation target is moving around. And then the testing spots appear around it in the same proportion. And I think it's much more comfortable. I think that we all get complaints about, well, I was looking at that dot and it totally disappeared. Or I saw five dots in the center. Or I thought I saw the dot, but then it seemed to totally go away. Or all kinds of hallucinatory experiences. I mean, the human eye is not intended to stare into a bright, white bowl for more than a few seconds. So I think that this sort of thing might actually come up. This is a printout of one of those early tests. The other thing you guys need to know about is that there are a bunch of screening tests out there. These are a money-making proposition. Some patients, when they go to their eye doctor, they sort of offer to menu, what would you like to do today? Do you want some photographs? Do you want to visual field? And some people will say, yeah, sure. And I've actually seen patients with a visual field defect picked up because they said, yeah, sure. And they had no idea anything was wrong and off they went. But these screening tests are extremely efficient. This is one of them where you have a sort of sinusoidal grading that's sort of moving. And so the patient will tell you that they were looking into a little viewer and a little kind of flickering thing appeared all around in their peripheral vision. It's only 16 test points for this particular one. And so it was specifically designed to try and capture M cell, neuronal death. I don't know that it really does, but it's nice because you don't have to be in a dark room. It's just looking into this little doohickey. And it can tolerate a ton of blur. So refractive error is not so much of an issue. And this would be the printout that you get. This is like a perfect test result. And it's this little sort of strip that gets spit out of the machine almost like when you've done a lensometer, the automated lensometry. And so you can sort of see that there's the little black dot over here in the left. Eye is over here on the left. And then it goes all the way out to 30 degrees nasally. So it is intended to screen for glaucomatous problems. It takes a couple of minutes per eye. The screening one is 45 seconds per eye. It's fast. It's compact. It's portable. It's inexpensive. It can miss neurologic deficits because the stimuli don't respect the vertical. The targets are large, so small. Scutomata can be missed. But Dr. Wall, a neurothemologist in Iowa, did some data on this. And he concluded that it was actually quite sensitive for optic neuropathies. It's original intent, glaucoma. But it doesn't do very well with hemianopias. I have seen hemianopias picked up, but it's not very sensitive. So the advantages of automated perimetry, now we're moving into the artifacts. The advantages of the automated perimetry are lack of observer bias. So a golden visual field, for instance, in an experienced hand, can make show almost any defect that you think it should. So it's very easy as a voleman to find a defect that you intend. The Humphrey perimetry doesn't look at any of these pretest biases. It's very reproducible. And almost everybody in the country has Humphrey. The major alternative is octopus, which is a very nice test. But unfortunately, since the color print out doesn't fax very well, as my printer doesn't fax at all. But the other nice thing about the automated perimetry is that there are a bunch of different test strategies. And you've seen us in clinic doing testing with large, bright stimuli with bi-sized stimulus, et cetera. There are a lot of ways you can go about doing the test, even with automated perimetry. And I would say that in most cases now, a streaming or seed of fast will be faster than most goldmans, except for a goldman that's intended for driving. So driving valuation, goldman, which is a single-size stimulus, a three-size stimulus, the 35E, can take literally 30 seconds. You can get that done. The other thing that's nice about automated perimetry is very quantitative. And so if you're trying to follow a defect, then it's quite helpful. The disadvantage is that it's run by a machine. So there's no chit-chatting. There is adaptation for the patient, but not very much. And it is prone to artifacts. And we're going to go over some of those. So the players in inducing artifact and automated perimetry are the patient, the machine, and the technician. So the patient, pupil size matters. With very small pupils, you're going to get constriction. You do have to have accurate refraction. You do need the near add, because the bowl is at about 14 inches. It's pretty close to the patient's eye. Poor vision is a poor vision field. 2,200 vision, you have to adjust. People have high myopia, or better off, using their contact lenses, or even their glasses, because the machine has a lens in front of the patient's eye that those can need to artifact as well. Tosis on the part of patient, concentration, reaction time, neurologic data, so it can all play a role in your reliability of visual abilities. So if they're going to wear their contacts, do you just do a little refraction over them? Yeah. And the near add, whatever the near add might be. So patient teaching. The technician, whoever's doing the visual field, like Rhys here, these men in the visual field do today, you have to know what the patient's up for, right? If you don't understand the test, then you can't tell the patient how to do the test. And they need to tell the patient how to do the fixation, how to respond, even to dims stimuli. They have to be redirected during the test, but not too much, because if you're constantly hovering on the patient and moving your chin around and poking it in the back of the head and things to try and get their head aligned, then the patients can get very frustrated and annoyed. And sometimes they'll say that that was the best visual field I've ever done. And sometimes they'll say, that was so annoying. So the machine can be stopped in mid-flight, right? If you just hold down the button, then the machine stops. And so if the patient is told that they need a rest, and they need artificial tears, oh, my bad. They can stop the machine as it's going, and then just resume. Yes? Oh, here it is. I thought you were asking a question. I don't know what I was doing. Some patients simply cannot do pump-free visual field testing. Every time they do the test, it gets worse. And they start getting anxiety attacks and things. It's moderately stressful. The machine issues. You have to choose the right protocol. You have to know what you're looking for. You have to choose the right stimulus size, and the correct parameters have to be put in. There's a lot of information that has to get entered into the machine before the patient can even get started. And they have to put in the patient's age, the right correction, the pupil size, and they have to test the correct eye. So here's a classic artifact in visual field testing. What's going on here? It could be a rim artifact, or it could be ptosis. So both have to be looked at. In this case, the pupil is 2 milliliters, OK? And that's just not going to work. And so after the patient's dilated, you can see a lot better response. What happened here? Anybody have any suggestions? Any suggestion about the patient? Trigger navigating. This is too darn bright. They have very, very, very good vision, or they're just pressing a button willy-nilly. And unfortunately, the machine can tell. But look at that fixation losses. They're looking around. It's just not a very reliable false negative. It's not none. So they're just really going to town. And so what about that one here? Fogul threshold there, what's that? One decimal, right? That can't be good. That's just too dark. You can't do that test. So this is not a problem with the machine. It's a problem with the choice of the test. So with the three size there, they can't do much with the five size. You can actually maybe be able to follow that. So the one on the left is a three size. One on the right is a five size stimulus, OK? What's the deal here? Mostly. Yeah, it could easily be. What's this one called? Cloverleaf. Everybody see why? It's so lucky day. OK, so the cloverleaf is your fellow. I want to explain that a little bit. So the machines are kind of interestingly designed. The first thing the machine does is test these four little spots at about 10 degrees, which is, I put this in an amphibre. If you put an amphibre in the back of the hole, the four spots that are tested first are the one out of about 10 degrees, OK, which Amzard is out there. So those are the four testing spots. These other guys in the middle are as close to centrifugation as the machine gets, which is interesting. But so you can see here that so the physiologic blind spot starts at about 10 degrees. So here's where the physiologic blind spot would start, and so these testing spots are about 10 degrees. So you can actually have a reverse cloverleaf. This is where the patient didn't get the test. They didn't understand what's going on during the initial primer phase, and they just missed all four of the initial testing spots. So that tells you exactly, it's like a reverse cloverleaf. It tells you exactly where those first rounds of testing are occurring, right at about 10 degrees. OK, what happened here? Could be ptosis again. And so you can take the lid and get the ptosis out of the way. What happened here? Rim artifact, yeah. See how mechanical that looks? Just doesn't look like anything sort of physiologic, especially the one on the right. That's pretty impressive. So rim artifact, most often what's happening is that the lens is actually put, it's on this little standard, and it's put right up against the patient. And then over the course of the testing, the patient like that. And so they're looking sort of through this little ring. So it's best if you use kit lenses, but if you can't come up with the astigmatism correction that you need, then using the patient's own glasses as long as they're correctly positioned. Keep the patient awake and keep the head up against the force. It's just like when you're trying to do a slip line exam and the patient's falling back, you're like, I can't reach, you know what I'm saying? They're only an inch away, but this feels like they're... Okay, what happened here? The vertical position was on. Does anybody know how that would happen? I can tell you that it almost never happens in the other direction. Does that help? I've never seen it with the physiologic line spot displaced superiorly, never ever once. You want it, you want it? Okay, so this is looking into a comfrey individual field bowl, okay? This little thingy over here is the little camera that's watching the fixation. And so down at the bottom of the printout, there'll be that little line that shows how well the patient is maintaining eye position. So this thingy down here, this is the test that the machine uses to detect bogeal threshold. It's this little set of diamonds and it's a progressively brightening, kind of like a gringe colored stimulus and it's down below. So as you're doing a bogeal threshold, and that takes like maybe 30 seconds per eye, very, very helpful tests. As you're doing a bogeal threshold, that little portion of the test, blah, blah, blah, goes on, gets done. And then what's supposed to happen is the patient's supposed to move their fixation up to the central fixation target, okay? And that is literally right straight ahead of you in the bowl. And if you don't do that, then the whole test is typically done with the patient looking at the little diamonds here, down below. And that's, again, it's about 10 degrees off fixation. The blind spot is displaced inferiorly and you'll often get these spurious upper visual field defects because of course you're testing way more peripheral vision than the machine is intended. Make sense? It's a mechanical problem with fixation. And it happens all the time. And patients will say, well, I thought it was kind of weird, but you know what, I just did what I was told. Or the tech will say, well, I know it all looks right ahead, but they just seem like they weren't fixating properly. And machines go nuts because they can't find the physiological blind spot, et cetera. So what happened here? Is this patient radically getting worse over time? There she is. She's got a pretty nice visual field on the right there and her little meningioma, is it like expanded and just gotten dramatically worse? You can see there's generalized depression there. And is it worse? Could be. Let's do another MRI. Or we could check the parameters here. Somebody put in her date of birth incorrectly. Right? And the machine thinks she's only 40 years old instead of 50 years old. And so she's being judged much more harshly, right? A 40-year-old and a 50-year-old will not have the same field of vision. And these machines are calibrated for age. So you're compared not against, you know, 25-year-old lab rats, you're compared against your peers. Are they in, like, 10-year intervals, usually? Or how is that? I don't think that one or two years is probably gonna make much of a difference, but a decade would. And I don't know the answer to that question. I'm sure it's out there, but. I didn't know that. And I don't know. I don't know if it's bend or if it's a continuous variable. I'm not sure about that. But definitely a decade is gonna make a difference. So in automated pre-treat, there are patient-related artifacts. You have to prepare the patient. You have to coach them. You have to monitor them. Position them, dilate them, refract them. Take care of their ptosis and choose the right test. Right? You're not gonna be able to get a good result if you ask for the wrong test. And they're machine-related artifacts. You have to choose the right test strategy. You have to check the parameters. The demographics, the lens position, the stimulus size. And I say, be one with the machine. Right? You have to really understand how the test works. Because when patients come out to you and say, you know, that he's all making mouths in there, well, maybe they're not totally nuts. So I think, I encourage everybody to actually have a visual field done on them because it's a very interesting and somewhat unpleasant experience. Okay, so let's go over some cases. All right, so the first case was a 65-year-old guy who was referred by his neurologist to evaluate his vision. One year prior to when he came to us, he had had a hemorrhagic stroke. And since then, he noticed that he'd frequently been bumping into objects on his left side. And he was describing mycropsia and macropsia. So for him, when he would walk down a hallway, it would seem like the walls were getting bigger and smaller and bigger and smaller. So his acuity was 20-20 in both eyes. He had no APD. His motility and alignment were normal and his slit lamp of the anterior segment and his funnest exam were normal. Okay, so here is his Humphrey visual field. So how would you describe this field defect? Anybody, this is an easy one. What? Quadrant, very good, okay. So where was his hemorrhagic stroke? Right parietal, okay, so here is his skin. There it is in the right parietal. So I found this, I didn't create this diagram. So I don't know if this is against the rule, but I thought it was actually really nice, whoever did make it, describing kind of where the field projects onto the retina and then anatomically where that goes back, right? So he had a left lower quadrant tenopia, right? So it projects up here onto like the supranasal portion of the retina and the supratemporal here, right? So he's gonna come down through the optic nerve, cross through the chiasm, go back in the right optic tract, synapse in the lateral geniculate nucleus, come up into the parietal lobe through the optic radiations, right? I'm gonna say I'm on this side. Okay, so what other symptoms do you think this patient might have? This is some board review stuff. Let's say, what if it's his non-dominant hemisphere as most right-sided parietal lesions are put up here? I know, it's hard to look it up. So they get spatial disorientation, they can get dressing or construction apraxia. So dressing apraxia is when they have a hard time putting their clothes on, because as you can imagine, I mean, it's really easy for us, you don't have to think about it, but when you really think about what your brain is doing, you're deciding which side is up and where do the legs go in and where do the arms go in. So you have to really be able to appreciate the spatial relationship of the pieces and the parts of the clothing. Construction apraxia is when people have a really hard time either repeating a drawing or creating even a simple structure, like popsicle stick type stuff. If it's the dominant hemisphere that's affected, they can have dysphagia or aphagia, apraxia, and then Gerstman syndrome is a good thing to know for boards because they'll ask you about that. They have a hard time doing basic calculations, writing, finger, agnosia, sorry, that's misspelled, is out and they can't recognize and name the different fingers that they have and they have a hard time telling right versus left. And hemispatial neglect usually happens from a right-sided lesion causing left-sided neglect and that's because the right-sided space usually has redundant processing from both the right and left hemispheres, but for most left-brain-dominant people, the left-sided space is just processed by the right hemisphere. Okay, next case is a 21-year-old woman who came into triage. This was just before Thanksgiving because she'd been noticing a gradual loss of vision in her right eye. She thinks maybe somewhere like the past one to three months has been pretty slow. She's not had any changes in the left eye and she's been noticing some headaches several times per week for the past month and they last sometimes the whole day and she gets fairly light-sensitive with them. And she was seen here back in 2012 in Dr. Vitale diagnosed her with mutes in the right eye. There was a question of maybe whether or not it could be a multifocal coriditis but she felt like, well, it doesn't really matter if it's gonna go on its own so she just never came back. So her acuity was 2020 in both eyes. The technician that saw her and then dilated her thought that she maybe had an APD in the right eye and her motility and alignment were normal. Her anterior segment was unremarkable and on dilated exam the report that you get is that the left optic nerve is maybe a little hyperemic. So what would be the next step now? So somebody's called you and they're like, oh, I have this person sitting here, I'm not sure what to do. I've already dilated them. Revealed! Very good. So I put up here her confrontational field and even though she was dilated, we decided to just go ahead and get one and see what pops up. So how would you describe this? A homonymous, right? Yeah, yes, that's very good. So where would you expect to see a lesion? Or what part of the visual apparatus? Could be a lot of places, right? Like basically sort of anywhere behind the chiasm. It's somewhat Congress, maybe not, but what would you want to do to evaluate this? Sorry, did you say her complaint was her left eye? Her complaint was her right eye. Was her right eye? She didn't feel that there was anything going on in the left. Okay, so what would be the next step? Imaging. Imaging. What would you order? Okay. This is what came up on the MRI. So this actually turned out to be a hemangioperisitoma. So she just had that resected and she's still, she's in rehab now actually for that. So interestingly enough, so because she'd been having the symptoms for like one to three months and it was really gradual onset. I didn't, I thought stroke was less likely and so I thought it's fine to do the scan as an outpatient. The radiologist actually came out and talked to her as they were doing the scan and sent her to the ER because she's got this big left shift there, so. Okay, so I pulled this back up just to kind of reiterate the anatomy there. So this, her field defect was like this, right? So it's gonna be these on the retina, right? So then these are gonna come back in here and this comes all the way back here. So this is kind of, you have to think about this diagram being reversed in terms of the imaging, right? So this is the left side. Okay, the third case was a 43-year-old woman who was sent for a visual field defect found on automated pre-metry. So she had gone in to see an optometrist three months prior to when we saw her for an annual exam. I mean I say annual but she hadn't been to anyone for a long time but she just thought maybe she should get her eyes checked out. And the optometrist found bilateral optic nerve power and did fields and found these field defects. She herself has not noticed any changes really. So her past ocular history is significant for a lazy eye, so her left eye has been lazy ever since she was a little kid. And she told us that actually at age two she fell out of a second story window and she was in a coma for 90 days. And then she thinks ever since then the left eye has just kind of drifted out. And she hasn't had, you know, she's not had close follow-up by any means. So she thinks that she may have seen somebody maybe like 10 years ago, maybe it was like 20 years ago, so it doesn't really know. And a few weeks ago she started getting headaches a few times per week. So because of the field defects and the way that her nerves looked, the optometrist had her get an MRI and we had the read on it, not the images, but it was normal. So her best corrected acuity was 20, 20 in the right eye, 20, 70 in the left eye. She had a small relative efferent pupillary defect in the left eye. She had a very large left XT. That was very commentant. Her anterior segment was unremarkable and her nerve, so she had a little bit of rim that was pink, left superiorly and inferiorly and then temporally and nasally, there was no rim. So I'm sorry, I don't have a photo of that. So I'm just pulling this up to show you it was very thin. Okay, so here was her confrontational field. So what would you like to see next? Her Humphrey. So there it was, so how would you describe this? Yeah, bi-temporal field defect. Okay, so where would you expect to see a lesion? Right, somewhere near the chiasm. Okay, so the MRI, which was done specifically to evaluate a bi-temporal field defect was normal. They saw no pituitary tumor, so now what? Very good. What other things, let's assume that it's not like a terrible radiologist that just missed a huge pituitary tumor, because that would be pretty unlikely, right? What's that? Like other medications. That's good, she's not on any medications. What other things could give you a bi-temporal field defect besides a pituitary tumor? I know it's the one you think of right away, but what? You would probably see it by the aneurysm. An aneurysm, very good, anything else? What? No, I'm saying besides a tumor. Forget a tumor in that area. But that's good, yeah, if it was coming up from below. Other kinds of tumors. Other kinds of tumors, yeah. No tumor. Very good, you can get a chiasmitis from that. Yep, very good, you can get it from sarcoid. And what else? What other disease that's autoimmune can cause inflammation of the nerves that maybe could also cause inflammation of the chiasm and you? MS, yeah, very good. So you can get a demyelinating lesion that gives you a bi-temporal field defect. And also, and I don't know if you guys will come up with this, I certainly did not. This woman has this really significant trauma history, right, she fell out of a second story window, she was unconscious for somewhere around three months. Is there any way that that could give you a field defect that looks like this and how? So you can get a sheer injury to the chiasm from blunt trauma like that. So we requested the images to look at them. And I'm not sure how well this is gonna show up, but she had these cystic spaces like surrounding the chiasm, so that's CSF there and this is just another little slice and like here and here that confirmed the suspicion that she'd had a sheer injury to the chiasm back when she was a kid and that's why she didn't notice any changes, whatsoever in her vision. Because you'd think that if it was really new, you would notice something like that. Although to be fair, most patients don't. A lot of times they don't notice that they have trouble with their vision until they're using monocular viewing and trying to read the eye chart and they can't read the right half of the eye chart with their right eye or the left half of the eye chart with their left eye. That's true. So to be fair, you know, with both eyes together, you can often see pretty well. Don't tie it off again. Exactly, what is? All right, so we'll actually come back to that too. Okay, so the fourth case is a 44 year old guy who went in to see his optometrist at the end of October because he noticed this black caterpillar in the left super temporal visual field. So it was just kind of like sitting right there. And they found that he had swollen optic nerves on both sides. So an MRI was done which revealed an occipital tumor and that was resected and it was found to be a meningioma. But he's coming in to see us because he's had blurred vision in both eyes since the surgery. And he thinks maybe it's getting a little bit better but he's having a really hard time like reading and he's a very smart guy and he can't really do his work right now. So his central or his corrected acuity is 20, 25 in the right eye, 20, 20 in the left. He had no APD. His motility was fine. He was orthophoric. His confrontational fields were full. His color vision was a little bit down. Sanctuary segment was normal. And on fundus examination, his nerves are like this. Okay, so now what? What kinds of things will you ask him about? Okay, good. His only medication is capra. Thanks. He gets headaches like occasionally, like maybe once or a couple of weeks, but that's it. He's had a couple of those that he's noticed. It's not happening very frequently, but he has noticed that. What? Yeah, he's noticed that a few times. He thought it was like raining outside and then realized that he was just hearing something in his ear. Okay, so what's the next step? Visual fields. And here's what they look like. Okay, so how would you describe this? Let's start with the blind spots. What would you say about that? Yes, they're both enlarged, right? And then what else does he have going on there? They kind of are seco-central, right? They're sort of, you know, right there. But I think, and it's a little bit hard to tell, but you can kind of appreciate that there's a little bit of like a homonymous nature to that there. But so could you get a seco-central scatoma in the enlarged blind spots based just on his disc swelling? What? Not usually? Yeah, so that'd be really unlikely, right? So remember we talked before about how with papillodema or discodema from that, it's like really unlikely to get central vision loss until it's really late. So it'd be very odd to have everything else in the periphery fine and then just the central one. So that, just looking at that right there should make you think, oh, that's probably something besides just disc swelling. So if we say, okay, yeah, there's a little bit of a right homonymous, a little bit of a left homonymous, where do you expect to find a problem? Something on both sides, right? It's probably behind the chiasm, but. And it gets central, it gets central in the entire face. Right, so pretty far back in the occipital lobe. Okay, so I'm gonna show you his pre-op scan. So that's his meningioma there, more in the right occipital lobe. And this is a coronal view. So what I wanted to point out here is how it's sort of enveloping and surrounding the confluence of sinuses there. And this is post-operatively. So I don't know how well it's really coming up there, but so you can kind of appreciate, this is a flair image, that he's got something going on here and something going on right there. So he's had, what, I heard a whisper. Does anyone know what's happened to him? Yeah, so he's kind of, so he's had bilateral occipital strokes. So they've removed that huge tumor, and then luckily he was just left with pretty small strokes, but sin both occipital lobes there. So, but he's still got all that disc swelling, right? So what's the deal with that? Yeah, so we wanted to also look at the sinuses and see what was going on there. You know, as you remember, it was all kind of wrapped around the turcular, so he would be definitely at high risk for getting some thrombosis there. So this is the sagittal view, and I don't know if you can appreciate there. So he has, you know, clotted off his sinuses pretty well. So we put him on anti-quagulation, and we'll see how he does. He's still walking and talking, and he's alive, and he's not really miserable, so I thought that was really surprising. Okay, so. I would just say, though, that blurred vision, that was his complaint with blurry vision, and you know, you might think, well, maybe the blurred vision is from this pamphlet human, but it's the visual field that told us that, no, this blurred vision is not a pamphlet demon. This blurred vision is related to this sensual visual field defect, and because he had it on both sides, he had that inferior, homonymous defect in the right and then on the left. Can you see how, now, going back now and knowing that he has bilateral occipital hole, they're not big infections, they're little ones, from removing this tremendous tumor that was wrapped around his hole close to your aspect of his occipital lobes and his pantocular. You can kinda see how this could happen, and the bigger field defect seems to be, well, it was in his, his right eye was the bigger field defect. Oh, oh my God, yeah. Well, where's my thing, dang it. Back, back, yeah, there. I think they're both bad, you know, because they're right there, so anyway, but it's bilateral. It's a very nice case, though, to how the visual field really, really helps you go, wow, well, this isn't his pamphlet demon. This is definitely something else. Okay, so I, I know we've seen some patients like this, and I was going through trying to find them, but I couldn't, so I can't show you their specific fields, but can anybody think of a scenario where one brain lesion can give you a homonymous hemianopecia, optic discontrophy on both sides and a relative efferent pupillary defect? What? Would that give you an efferent, what? Yes, the tract, the tract. So can you tell me which side the efferent pupillary defect would be on? Like ipsilateral or contralateral? Yes, why? What are the fibers across? Yes, it's very good. And what would the atrophy look like? Yes, can anybody explain why? Sort of, but not exactly. So that was... That's the, that's a lot of make-up notation there. Okay, so I thought I also didn't make this picture. I don't know if I'm allowed to put it in here, but I just thought it was a really nice illustration. The best one I could find, so. Actually, it was stolen from Bill Lloyd's paper. Was this one from his paper? Jim Hara has taken this drawing from Bill Lloyd's semi-optic triple-plusia article of 1968 or something. So don't feel bad about it. Okay, so let's say, so this is, we're gonna say this is the right eye, okay, this is the left eye. So here's the right nerve, the right tract, left nerve, left tract. So let's say you have a lesion here in the left tract. So the fibers that you're gonna hit from, let's say the left eye, it's gonna be the temporal retinal fibers, right? They come back here, they come back here. So temporal meaning temporal to the phobia. So these fibers come here and they come into the disc superiorly and inferiorly here. The fibers that you get from the right eye are gonna be the ones from the nasal retina, right? The ones that will cross here and go into the left tract. Nasal meaning nasal to the phobia. It's gonna be the papillomacular bundle here. Then these are the temporal retinal fibers coming in and then here's the other nasal retinal fibers coming in. So you'll get atrophy here and here, which is why it's called the bowtiatrophy. Does that make sense? And then you're still gonna, you're gonna have a homonymous defect. Does that make sense? How do I explain this? Okay. All right, quiz time. In the analysis of an automated static central 24-2, a Congress incomplete homonymous hemianopia is least likely to result from a lesion at the one. Which of the following visual fields is the best one to perform? Confrontational, tangent, Humphrey, Goldman, any. A patient with 20-20 vision in both eyes has a right afferent pupillary defect, localized pallor of both optic nerves and a partial right homonymous hemianopia. The most likely explanation is, everybody have a paper copy? Like, is it totally pointless for me to do that? There are some that don't? Yeah. Okay. Well, I can bring it on, bring it on. Does it be else missing a copy? Put your heads down and get to work, kids. And we'll go over this with the answers. If I can remember anything. They're kind of tricky questions. Is somebody missing the second page? No, please. Oh, yeah? Can I tell you? I can't, I don't want to explain what I'm doing. Do you have page two? So remember, I'm a neurologist. So we don't listen to the patient, I just said. Do I read it to you? Dear Ray. Ha, ha, ha, ha, ha, ha, ha. Dear Ray, I'm doing great. I was in the hospital for a while, but I'm back now and everything seems to be just fine. So you just won't let me drive. I don't even quite understand why. Ha, ha, ha, ha, ha. They tell me I had a stroke. But I feel fine. Much love. Hope to see you at Christmas. This is an actual letter from an actual person to my actual letter. Ray. Okay. Charmingly giving you. So, a congruous, incomplete, non-saminopia is least likely, I hate the least likely questions. So what do you guys think about number one? Congruous, I think this is good. Complete visual field, complete heminopia. I wouldn't tell you anything, right? Because you don't get the congruity that's complete. It's all complete heminopias are totally congruous. I don't know what you think of it. So I think in the greater principles of things that are more posterior than more congruous, so all I was trying for here is the furthest forward. So I would go with object tracking. So which of the following fields is the best one to form? Anything, anything. It's okay. Okay, and then write it down. So 2020 vision, a right APD, localized power. Partial heminopia, the most likely explanation. I mean, many of these are possible, but the most likely, the nice way to put it all together. Pardon? B. B, B, sorry, I thought somebody was saying something. Okay, a congruous, homonymous, superior co-identitonomy, it may result from any of the following except. I love the gradations. I should stop answering questions all out. Well, so parietal should give you more inferior, right? So it could be a temporal lobe, right? But these are, I don't know, somehow the one that I sent you, I corrected it, so the written one is better written than the, than those ones there. So it could be the optic radiations, right? And so you could get a lesion in the optic radiations from the explosives, a nice, co-identitonomy from the posterior pole, and it includes you from the MCA. What's the conclusion of the MCA? Could you add more conclusion on the MCA? Of course. So, yay! I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. Yeah, so the optic radiations in the parietal lobe should be a few in here. That's the only one that does the test. Good. Okay, a monocular visual field effect. And why is, why can you get a monocular field effect in the monocular field effect? How can you get a monocular field effect in this box? What about the temporal pressives? Yeah, exactly. What part of the exit but a lobe would be hit? The most anterior part of it. So there's a lobe on the box. The fixation in the right visual field where the optic mirror vanishes the eye. Right. So that's E, B. All right, so the most likely region, painless sudden onset, middle-aged woman, otherwise normal. And so, now in this I'm, you know, it's like most likely painless sudden onset. And I'm talking about sudden onset. Now there are two possibilities. How long is that to her that she never said what we're saying? To me? To me? I would say to her. It could be nerve or retina, but what's more common? Okay, so what about the actual defect itself? Does that give you information? Yeah, you have a nasal, inferior means of stuff and then a superior also, you know, like partial, almost all of them are superior. Yeah. So theoretically, the retina is gonna give you less likely, is less likely to lose something that crosses the horizontal meridian because of the vascular supply kind of stuff. You can leave that there. And then this is the line spot of the water. This line spot is in water, does another thing. And I would venture to say that interesting doctor, roughly maybe more common than retro-watered illusions. So I'm good with no appearance. Okay, Rhys, what do you think about this letter? You're right. I don't know. I can't tell from the picture what it's trying to show, but I'm not sure if it's supposed to be like a neglect or something. Yeah. I was gonna say opposite at all. Okay. What? I gave you the whole explanation about having neglect.