Reminder of important clinical lesson

CASE REPORT

Perimetric demonstration of spontaneous visual field
recovery following occipital lobe haemorrhage
Siying Lin, Badie Z George, Nicholas J Wilson-Holt
Department of Ophthalmology,
Royal Cornwall Hospital, Truro,
UK
Correspondence to
Dr Siying Lin,
syserlin@gmail.com

SUMMARY
A 45-year-old patient on lifelong warfarin therapy after
a metal aortic valve replacement developed a
homonymous visual field defect following an occipital
lobe haemorrhage. The patient received only
conservative management and yet described continued
improvement in her visual field defect for up to
20 months following the initial cerebral insult. We
present the first conclusive illustrative documentation
of visual recovery in a patient with an occipital lobe
haemorrhage with sequential automated perimetric
assessments over an extended period of time.

In this case report we describe a patient who developed a homonymous visual field defect following a
spontaneous intracranial haemorrhage. For the first
time in literature we followed the patient with
serial automated perimetric assessments charting
resolution of the defect.
We feel this article would appeal to neurologists
as well as ophthalmologists caring for patients who
have suffered visual field defects following an intracranial insult.

heparin prior to being restarted on warfarin and discharged from the hospital.
The patient was reviewed in a neurosurgical
clinic 4 months later. She described a gradual
improvement in her visual fields, but with a persisting left-sided defect. At this point the patient was
referred to the ophthalmology department for
assessment of her visual fields.
On examination, the patient’s visual acuities
were measured at 6/4−4 in the right eye and 6/5+3
in the left eye. An ocular examination was unremarkable with healthy optic disc appearances and
no significant retinal pathology. Automated perimetry testing on a Humphrey visual field analyser II
was first performed 7 months postpresentation, and
showed a persistent left inferior homonymous
quadrantanopia consistent with the occipital location of the haematoma. Further visual field testing
performed at 10, 14 and 19 months postpresentation showed gradual resolution of the visual field
defect (figure 2). Binocular Esterman visual field
tests also showed gradual recovery of central visual
field, with the patient eventually achieving fitness
to drive under driver and vehicle licensing agency
regulations (figure 3).

CASE PRESENTATION

DISCUSSION

BACKGROUND

To cite: Lin S, George BZ,
Wilson-Holt NJ. BMJ Case
Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2013010494

A 45-year-old woman presented to the emergency
department with a severe headache of sudden
onset. Her medical history included a metal aortic
valve replacement for aortic stenosis, for which she
was on lifelong warfarin therapy. She was also
known to be suffering from mechanical intravascular haemolysis associated with a failing aortic prosthesis. There was no other significant medical or
surgical history of note.
Testing of confrontational fields revealed a left
homonymous hemianopia, but clinical examination
was otherwise unremarkable, with no other neurological deficits. A non-contrast CT scan of the head
showed a large intraparenchymal haematoma in the
right occipitoparietal area, with associated oedema
and midline shift (figure 1). A coagulation screen on
admission revealed an international normalised ratio
(INR) was 3.9, and this was rapidly reversed by
treatment with intravenous prothrombin complex
concentrate and vitamin K. Following neurosurgical
advice, the patient’s haematoma was managed conservatively. The patient remained clinically and
neurologically stable following a period of observation, and a repeat CT scan of the head performed
2 weeks postpresentation showed some resolution
of the intracranial haematoma. At this point the
patient was restarted on low-molecular-weight

Lin S, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010494

Homonymous hemianopia is a form of visual field
defect that can be caused by a variety of cerebral
lesions. In adults, a homonymous hemianopia is
most commonly caused by a stroke, with an occipital infarct being the commonest underlying

Figure 1 Non-contrast CT head scan performed at
onset of symptoms show a large intraparenchyma
haematoma in the right occipitoparietal lobe with
significant associated oedema and mid-line shift.
1

Reminder of important clinical lesson

Figure 3 Binocular Esterman visual field test showing preservation of
central visual field allowing fitness to drive under driver and vehicle
licensing agency regulations.

Figure 2 Sequential Humphrey 24-2 automated perimetric visual
fields performed at (A) 7 months, (B) 10 months, (C) 14 months and
(D) 19 months postinitial intracerebral insult, showing gradual
resolution of the left homonymous visual field defect.
pathology.1–3 In fact, on careful examination 20% of patients
with an acute stroke will show clinical evidence of a hemianopic
field defect.4
Homonymous hemianopias are often very disabling, with
patients reporting difficulties with reading and visual scanning.
They may fail to notice relevant objects or avoid obstacles on the
affected side, and collide with approaching people or cars.5 The
homonymous visual field defect may also affect their legal ability
to drive.6 7 This can have significant consequences on the patient
functional independence and ability to maintain employment.
Patients and caregivers are therefore often keen to obtain information regarding the timescale and prognosis for visual recovery.
Studies of visual field recovery in homonymous hemianopias
suggest that spontaneous improvement of visual field defect
occurs in nearly 40% of patients.8 In most cases the improvement is usually seen within the first 3 months following the
intracranial insult.8–10 Improvement after 6 months from injury
was often mild, and thought to be related to improvement of
the underlying disease or increased ability at performing the
visual field test reliably on follow-up visits.8 11 Our patient
however, described continued objective, improvement in her
visual fields for up to 20 months following the initial cerebral
insult. We speculate that the improvement demonstrated in this
2

patient may be due to a difference in the underlying pathology.
Our patient’s homonymous hemianopia was caused by a
primary intracranial haemorrhage, whereas, in the above studies
of visual recovery in homonymous hemianopias, the causative
insult was most commonly a cerebral infarct.8–11 Reversing
anticoagulation in patients with proembolic states who have suffered an intracranial haemorrhage is always a balance of risks
and benefits. Stopping anticoagulation for 7–14 days appears to
be generally well tolerated, but should only be undertaken after
discussion with senior stroke or neurosurgical physicians.12
Our case report is the first to our knowledge to conclusively
document visual recovery in a patient with an occipital lobe haemorrhage with sequential automated perimetry over an extended
period of time. Although the patient did initially present with a
left homonymous hemianopia on confrontational fields testing, no
formal perimetric visual fields were obtained until the patient was
referred to the ophthalmology services 6 months later. By this
time, the patient had reported a subjective improvement in her
visual field symptoms. We were subsequently only able to demonstrate a left homonymous inferior quadrantanopia, in keeping
with the occipitoparietal location of the intracranial haemorrhage.
Automated perimetry appears to be a more sensitive method
of accurately assessing visual field defects following a stroke
compared with non-perimetric confrontational assessment, and
can be useful in decision-making regarding eligibility for
driving13 14 (figure 3). In addition, anecdotally, patients who are
improving seem to benefit psychologically from being shown
objective evidence of their clinical improvement. We would
propose setting up a study to assess patients’ perspectives on
formalised perimetric visual field testing following an intracranial event. In the future we feel that automated perimetric
assessments of visual fields would be a useful adjunct in the
assessment and rehabilitation of stroke patients with homonymous visual field defects.
Lin S, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010494

Reminder of important clinical lesson
2

Learning points
▸ Hemianopic visual field defects are present in up to 20% of
patients who have suffered an acute stroke. Initial work-up
of such patients should therefore include an assessment of
visual fields by both confrontational fields testing and
automated perimetric testing if possible.
▸ Homonymous hemianopias following acute cerebrovascular
events can show continued improvement for up to 20 months
following the intracranial insult, although in most cases the
improvement is usually seen within the first 3 months.
▸ Automated perimetry can be used to accurately assess
baseline visual field defects following a stroke, as well as
objectively document any improvements. It can also be
useful in decision-making regarding eligibility for driving.
Contributors SL wrote the manuscript. BZG edited the manuscript. NJW-H edited
the manuscript and provided advice on the final draft.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1

3
4
5
6
7
8
9
10

11

12

13

14

Trobe JD, Lorber ML, Schlezinger NS. Isolated homonymous hemianopia. A review
of 104 cases. Arch Ophthalmol 1973;89:377–81.
SMITH JL. Homonymous hemianopia. A review of one hundred cases. Am
J Ophthalmol 1962;54:616–23.
Isaacs B, Marks R. Determinants of outcome of stroke rehabilitation. Age Ageing
1973;2:139–49.
Pambakian AL, Kennard C. Can visual function be restored in patients with
homonymous hemianopia? Br J Ophthalmol 1997;81:324–8.
DVLA. At a glance: Guide to the current Medical Standards of Fitness to Drive.
(Issued by the Drivers Medical Group DVLA) 2012.
Royal College of Ophthalmologists. Visual standards for driving. 2005. http://www.
rcophth.ac.uk/core/core_picker/download.asp?id=214
Zhang X, Kedar S, Lynn MJ, et al. Natural history of homonymous hemianopia.
Neurology 2006;66:901–5.
Gray CS, et al. Recovery of visual fields in acute stroke: homonymous hemianopia
associated with adverse prognosis. Age Ageing 1989;18:419–21.
And KT, Kolmel HW. Patterns of recovery from homonymous hemianopia
subsequent to infarction in the distribution of the posterior cerebral artery.
Neuroophthalmology 1991;11:33–9.
Messing B, Ganshirt H. Follow-up of visual field defects with vascular
damage of the geniculostriate visual pathway. Neuroophthalmology
1987;7:231–42.
Phan TG, Koh M, Wijdicks EF. Safety of discontinuation of anticoagulation in
patients with intracranial hemorrhage at high thromboembolic risk. Arch Neurol
2000;57:1710–13.
Çelebisoy M, Çelebisoy N, Bayam E, et al. Recovery of visual-field defects after
occipital lobe infarction: a perimetric study. J Neurol Neurosurg Psychiatry
2011;82:695–702.
Townend BS, et al. Perimetric homonymous visual field loss post-stroke. J Clin
Neurosci 2007;14:754–6.

Zhang X, Kedar S, Lynn MJ, et al. Homonymous hemianopia in stroke.
J Neuroophthalmol 2006;26:180–3.

Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
http://group.bmj.com/group/rights-licensing/permissions.
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
▸ Submit as many cases as you like
▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles
▸ Access all the published articles
▸ Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact consortiasales@bmjgroup.com
Visit casereports.bmj.com for more articles like this and to become a Fellow

Lin S, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010494

3