LESIONS OF VISUAL PATHWAY

Moderator/Faculty: Dr. [Col.] Y S Sirohi sir & Dr. Jyoti Bhatt ma’am
Resident : Dr. Anubhav Singh
Lesions of Visual Pathway
• Visual Field Defects
• Ipsilateral monocular visual loss: This is due to a lesion in the
optic nerve, causing complete visual field loss in the ipsilateral
eye.
• Bitemporal hemianopia: This can be due to a lesion of the optic
chiasm or compression of the optic chiasm, as is seen in
pituitary adenomas and craniopharyngiomas disturbing the
medial portions of each optic nerve as they cross here. With one
eye closed, the other eye loses vision in the temporal visual
field.
• Unilateral anopia: This is due to a lesion in the optic tract on the
side of the anopia..
• Homonymous hemianopia: This is due to a lesion in the
optic radiations in the visual cortex on the contralateral
side of the anopia
• Homonymous hemianopia with macular sparing: This is
due to a posterior cerebral artery (PCA) stroke.
The PCA supplies the occipital cortex, where visual
processing for the contralateral side takes place. A PCA
stroke will, therefore, lead to contralateral homonymous
hemianopia. The reason the macula is spared
is that the macula has a dual blood supply from both
the middle cerebral artery (MCA) and the posterior
cerebral artery.
• Upper quadrantanopia: This can be due to a lesion in the temporal lobe or a
middle cerebral artery (MCA) stroke in the contralateral side of the anopia. 
• Lower quadrantanopia: This can be due to a lesion in the parietal lobe or an
MCA stroke in the contralateral side of the anopia. 
• Central scotoma: This defect of central vision occurs in lesions of the
macula, such as macular degeneration, cystoid macular edema, and
inflammatory macular disease.
• The ipsilateral monocular visual loss can be permanent or transient. In the
latter case, we speak of "amaurosis fugax" or "transient monocular
blindness." Amaurosis fugax is generally due to interruption of blood flow
(ischemia) at the level of the optical pathways, for example, caused by
retinal embolism or by severe homolateral carotid atheroma stenosis (usually
near the common carotid artery bifurcation) or other causes of ischemia in
the visual cortex or optic nerve. Possible causes are:
• Retinal embolism
• TIA (transient ischemic attack)
• Cerebrovascular accident
• Traumatic brain injury (e.g., falls, motor vehicle collisions, etc.)
• Dissection of the internal carotid artery
• Giant cell arteritis
• Emboligenic heart disease
• Coagulopathies
• Retinal migraine
• Carotid artery stenosis
• The term hemianopia or hemianopsia refers to a visual impairment characterized by the inability to perceive
half of the visual field. The disorder can affect one eye or both; we can speak of lateral or vertical
hemianopsia and superior or inferior hemianopsia (altitudinal or horizontal hemianopsia). The disorder can
affect one eye or both. There is lateral or vertical hemianopsia and superior or inferior hemianopsia
(altitudinal or horizontal hemianopsia). Other definitions include heteronymous bitemporal (loss of the
temporal visual field of each eye due to a median lesion of the optic chiasma); binasal heteronymous
hemianopsia (the left half of the visual field of the right eye and the right half of the visual field of the left
eye is negatively affected due to bilateral lesions affecting both edges of the optic chiasm, which is rare;
hemianopia homonymous (loss of the right / left visual field due to an injury to the left/right optic tract); and
quadrantanopia (the loss of a single quadrant of the visual field).
• The scotoma can be relative or absolute; in the first case, the alteration is related to a decrease in the
sensitivity of the retina (one is no longer able to perceive some or all colors, except for white), while in the
second case, this sensitivity, in some areas, is of the all absent (the image is no longer perceived or in any
case, perceived minimally). The disorder can affect one or both eyes. The term derives from the Greek
("skotos," darkness, dark). The scotoma can also be negative or positive; in the first case, it is a non-vision
area within the visual field (the subject perceives a dark spot on the fixed objects). In the second case,
there is the perception of an intermittent bright spot of variable color. A scotoma is generally referred to as a
pathological alteration of vision, but it should be specified that there is also a physiological scotoma, the so-
called blind spot or blind area of Mariotte; it is a point of the eye where vision is absent, the so-called optical
papilla, an area where photoreceptors are absent. Examination of the visual field (campimetry), the scotoma
is graphically represented as a black area located centrally or peripherally). Scotoma is one of the
symptoms of various diseases affecting the functionality of the eye, and the ocular structures involved may
be different; the main causes include:
• Macular pathologies
• Retinal detachment
• Cataract
• Glaucoma
• Optic nerve alterations
 CHIASMAL LESIONS
Junctional scotoma:
 Visual field patterns from kinetic perimetry testing and Humphrey 30-2 program
testing (insets). Note the central scotoma in the patient’s left eye along with the
superotemporal depression in his right eye
 JUNCTIONAL SCOTOMA
B, Coronal image of a section in front of C 
the optic chiasm showing a tumor Coronal image at the level of the optic
compressing the prechiasmic segment of chiasm showing minimal rostral
the left optic nerve (long arrow) but not displacement (arrow) but no notable
the right optic nerve (short arrow). direct mass effect
 PITUITARY ADENOMA

C, coronal MRI scan shows an intrasellar enhancing

mass, with extension into the suprasellar cistern and
upward displacement and compression of the
chiasm (arrow)

Pituitary adenoma. A,
B, Visual field patterns from a
patient with a pituitary tumor,
showing bitemporal
depression worse superiorly,
with margination along the
vertical midline
 PITUITARY APOPLEXY

Acute compressive optic neuropathy in pituitary apoplexy. Coronal (A) and sagittal (B)

MRI scans show a large pituitary tumor with suprasellar extension. Inhomogeneity
within the tumor represents hemorrhage and infarction
 OPTIC TRACT SYNDROME

Lesions involving the decussating nasal retinal fibers (represented by the dashed red line) can
result in bowtie atrophy
Relationship of the lateral geniculate nucleus to nearby structures and its blood supply. AChoA = anterior
choroidal artery; BC = brachium conjunctivum; CerePed = cerebral peduncles; ICA = internal carotid
artery; LGN = lateral geniculate nucleus; MCA = middle cerebral artery; MGN = medial geniculate nucleus;
ON = optic nerve; PCA = posterior cerebral artery; PCoA = posterior communicating artery; PLChA =
posterior lateral choroidal artery; Pulv = pulvinar; RN = red nucleus; SC = superior colliculus; SCA =
superior cerebellar artery
 LGB VISUAL FIELD DEFECTS
Visual field defects of the lateral
geniculate body (LGB). Automated (B) a loss of the upper and
visual field testing shows (A) a lower homonymous
central wedge- shaped quadrants, with preservation
homonymous sectoranopia caused of the horizontal wedge
by lateral posterior choroidal artery resulting from occlusion of
occlusion the anterior choroidal artery
 TEMPORAL LOBE
Visual field patterns after partial left temporal lobectomy
for seizure disorder. A, Kinetic perimetry visual field
results show a predominantly peripheral right superior
homonymous quadrantanopia sparing fixation.
Humphrey 30-2 perimetry testing
detects a minimal portion of the field
defects
 OCCIPITAL LOBE
Occipital lobe infarction. A, B, Visual field
patterns show congruous right axial MRI scan showing left parieto-
homonymous hemianopia respecting the occipital stroke (arrows) sparing the
vertical meridian and sparing fixation occipital tip
 RIGHT OCCIPITAL LOBE STROKE

A 60-year-old woman presented with 3 episodes

of transient visual loss to the left side. Her visual
acuity was 20/20 bilaterally, but visual field
patterns demonstrated a left homonymous
hemianopia (A). Her temporal crescent was
intact on the left side, and an MRI scan
(B) confirmed the presence of a right
occipital lobe stroke (straight arrow)
compatible with an infarct and
sparing of the anterior visual cortex
(curved arrow)
 ArterioVenous Malformation OCCIPITAL TIP

An 18-year-old woman presented with an 8-day history

of sharp, left-sided headaches. Visual acuity was 20/20
bilaterally. A, B, She missed letters on the right of the
 Her angiogram revealed an
chart, and bilateral 10-2 programs demonstrated a tiny
arteriovenous malformation involving
1° homonymous scotoma just below and to the right of
the occipital tip (arrow)
fixation in both eyes
 PATTERNS OF VISUAL FIELD LOSS IN OPTIC
NEUROPATHIES
A, Cecocentral scotoma in the left eye (left; arrow); paracentral scotoma in the right eye 
(right; arrow). B,  Central scotoma in the right eye (arrow). C,  Arcuate scotoma in the
right eye (arrow). D, Broad arcuate (altitudinal) defect in the left eye (arrow). E, Nasal arcuate
(step) defects in both eyes (arrows). F, Enlarged blind spot in the right eye (arrow), worse
than in the left eye.
 OPTIC DISC DRUSEN
A, Fundus photograph of the ONH with buried drusen. The ONH margin is blurred, with yellowish opacity
of the deep peripapillary tissue. The retinal vessels are clearly visible overlying the ONH. B, Fundus
photograph of the ONH with papilledema. The ONH margin is blurred, with grayish- white, opalescent
thickening of the peripapillary nerve fiber layer (arrow). The retinal vessels are partially obscured at the
ONH margin and within the peripapillary retina. There are exudates from chronic edema just temporal to
the ONH. C,  Surface drusen demonstrate prominent refractile nodules on the ONH surface, which do
not obscure retinal vessels. D, Astrocytic hamartomas are nodular masses arising from peripapillary
retina and obscure the retinal vessels.
 MYELINATED NERVE PATCH

Myelinated nerve patches are often present within the arcuate bundles,
occasionally abutting the ONH. When they are contiguous, these nerve patches
may be mistaken for ONH edema or cotton- wool spots
 OPTIC DISC DRUSEN
A, Fundus photograph showing blurred ONH margin with scalloped edge, refractile bodies on the ONH
surface and at the superior pole, mild pallor, and no obscuration of retinal blood vessels. B, Visual field
patterns confirmed the presence of a nasal step produced by drusen involving the right ONH. C, B-
scan ultrasonogram demonstrating focal, highly reflective (due to calcification) elevation within the
ONH (arrow), which persists when the gain is decreased. D, Preinjection fundus photograph
demonstrating autofluorescence (arrow). E, CT scan of the orbits. Calcified ODD are visible bilaterally
at the posterior globe–optic nerve junction (arrows)
 OPTIC NERVE HYPOPLASIA

The small ONH is surrounded by a relatively hypopigmented ring of tissue (double- ring sign). The
retinal vessels have normal appearance
THANK YOU