management of visual field defects

Branch retinal vein occlusion

START Causes: inflammatory conditions and
Is defect Is defect Does defect obey Does defect obey Is defect localised + Compression by arteries
no yes no no Prognosis is good.
homonymous heteronymous vertical midline horizontal midline correlate to findings Urgent 1wk referral to ophthalmologist. Follow up with FA
on ophthalmoscopy noticeable improvement – no treatment required if no
yes improvement laser photocoagulation should be considered.

yes

Branch retinal artery occlusion

Causes: Carotid embolism
Meningioma Prognosis is poor unless the obstruction is removed within a few
no hours. Emergency same day referral to ophthalmologist.
Is the defect Intracranial tumour of the Treatment include ocular massage (3 mirrored contact lens).
completely yes meninges typically affecting Anterior chamber paracentesis. IV acetazolamide.
congrous middle-aged women.
Most meningiomas are Is there a relative visual yes
considered non-malignant or field defect
low grade and they are often Yes
yes
Is there macular slow growing. As the tumour Central serous retinopathy
no yes
sparing Is the defect a central scotoma grows it causes A sporadic disorder of the outer blood-retinal barrier.
Causes: stress, hypertension, Cushing disease steroids etc.
with an upper temporal yes compression of the junction Prognosis is good although recurrences occur in about 1/3 to 1/2
of all patients. Routine referral to ophthalmologist within one
scotoma on other eye of the chiasm with the optic month.
nerve. Treatment may include argon laser photocoagulation which can
speed up recovery and reduce recurrence rates.
Surgery is the standard Glaucoma
treatment followed by Early stage.
radiation therapy in the Glaucoma is a neurodegenerative disease of the optic
Occlusion of the posterior event of incomplete nerve leading to ganglion cell death.
cerebral artery. excision. Treatments available are; Retinal detachments
Damage of the medication – Separation of the neurosensory retina from retinal pigmented
90% of occlusions here are Referral to GP is emergency epithelium.
occipital cortex. beta-blockers reduce intraocular pressure by
vascular in origin to further investigate. reducing aqueous secretions. (Timolol).
Causes: breakdown of the forces attaching the layers. Subretinal
May occur from a fluid fills the potential developing space.
Macular vision is situated Alpha-2 agonists decrease IOP by reducing aqueous Emergency referral to ophthalmologist same day.
no head injury. Is defect primarily
posterior in calcarine secretion and enhancing uveoscleral outflow, Treatments include laser photocoagulation, cryotherapy and
Emergency no superior and surgery.
cortex an area supplied yes yes (Brimonidine).
referral to GP is paracentral/ Mitotics – parasympathomimetic drugs that act by
mainly by a branch of the
required for arcuate stimulating receptors in sphincter pupllae and ciliary
middle cerebral artery,
further body, (pilocapine).
hence macular sparing. no
investigation Laser trabeculoplasty may also be used to enhance
Emergency referral to GP aqueous outflow.
is required for further Retinitis pigmentosa Trabeculectomy is an incision made between the
investigation. Inherited condition angle of the anterior chamber and the sub-tenon
affecting the light sensitive space this also enhances aqueous outflow.
cells in the retina. Referral to ophthalmologist is routine (ophthalmologist Age-related macular degeneration
Long term prognosis is must give the diagnosis) Irreversible vision loss.
Causes: failure to remove debris from retinal pigmented
Is defect a peripheral poor with eventual loss of epithelium.
yes Prognosis is poor.
scotoma (tunnel vision) vision. Treatment: multivitamins and antioxidants may reduce speed of
Treatment: supplemental progression, anti-vascular endothelium growth factor, laser
vitamin A if initiated early photocoagulation. Emergency referral to ophthalmologist same
no day.
may slow progression.
Referral to
Is defect
ophthalmologist is routine. Papilloedema
homonymous Swelling of the optic nerve head, secondary to raised
quadrantanopia intracranial pressure.
Causes: obstruction of the ventricular system, hydrocephalus,
Glaucoma certain medication or intracranial mass.
yes Progressing stages Emergency referral to ophthalmologist same day as
intracranial mass has to be ruled out.
Putitary tumor routine referral to Treatment is to reduce the intracranial pressure therefore the
Pituitary gland produces ophthalmologist to give Is defect a central/ yes cause must be established.

hormones that affect growth and diagnosis. cecocentral scotoma

the function of other glands in the Demyelinating optic neuritis
yes Pathological process normalmyelinated nerve fibers lose their
body.
insulating sheath.
Not all tumours require treatment Causes: most common is papillitis. Prognosis is good for
however patients should have a visions however colour, contrast sensitivity and brightness
appreciation may remain altered.
prolactin level assay carried out yes Referral to ophthalmologist is urgent one week.
Is blind spot Retrobulbar neuritis.
urgently. Treatment is by high dose steroids however benefits must
Is defect bitemporal, primarily enlarged Nerve damage which has outweigh the risks
yes Medication – dopamine agonists occurred behind the
superior quadrantanopia
may shrink tumour. globe. It is a
Superior Inferior Surgery – if tumour fails to Stargardt disease
demyelinating desease This is dystrophy of the macula. It is a juvenile condition
(pie in the sky) (pie on the floor) respond to medication. affecting the myelin no presenting around the ages of 10 – 20yrs. This is an inherited
Radiotherapy – often used sheath surrounding the condition.
Prognosis is poor as central vision may deteriorate to 6/60.
following surgery. nerve. The most Treatment: no cure for disease however sunglasses with UV
yes yes Gamma knife stereotactic – a common cause is protection may slow the dystrophy of the retina, low vision aids
are available .
relatively new method of delivering multiple sclerosis. Routine referral to ophthalmologist within one month.
radiation precisely to the tumour. Treatment consists of
Referral to GP is emergency. intravenous
Parietal radiations corticosteroids followed
Temporal radiations no Chloroquine retinopathy
Superior fibres of the by oral steroids.
These are lesions Antimalarial drugs used in the prophylaxis and treatment of
radiations corresponding Urgent referral required malaria and rheumatoid arthritis.
affecting the radiations These drugs are excreted very slowly and therefore a
to the inferior visual field one week. yes
shortly after leaving the Craniopharyngioma Is defect a perifoveal cumulative dose may be toxic on the retina containing
move directly melanin.
lateral geniculate Slow growing mostly benign ring Prognosis is good provided early detection. Referral to
posteriorally to the
nucleus. The lesions are tumours arising from the pituitary
ophthalmologist is one week where the patient can be
occipital cortex. screened and monitored. Medication maybe required to be
normally vascular in stalk. stopped.
Lesions here are
origin, selectively Treatment is mainly surgical, as
normally vascular in
involving the fibres in these tumours have a tendency to
origin
Meyer’s loop. adhere to the optic chiasm and
Emergency referral to GP
Emergency referral to GP Is defect bitemporal, primarily other nerves complete removal
is required for further yes no
is required for further inferior quadrantanopia may not be achievable therefore
investigation
investigation. radiation may be required as a
follow up. Some patients may
require hormone replacement
therapy post surgery such as
thyroid, testosterone or oestrogen. Tilted disc
Emergency GP referral is required yes Common congenital anomaly caused by an
Is defect bitemperoral oblique entry of the optic nerve into the globe.
for further investigation.
haemianopia Referral to ophthalmologist is routine. No
treatment as in most cases field defect is
corrected by refracted error.

Kelly Sharkey