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Background: Low-dose oral contraceptives can still cause thromboembolic disorders with serious neurologic or ocular disabilities., Patient: A 22-year-old woman having used oral contraceptives for several months noticed sudden painless visual loss in her left eye. One tablet of her contraceptive contained ethinylestradiol (0.03 mg) and chlormadinonacetate (2 mg)., Result: Because of the lower left eye visual field defect, the patient could only read with her right eye. She presented complete left inferior hemianopia, indicating a hemicentral retinal artery obstruction. Visual acuity in both eyes was 20 / 20. The left fundus revealed a distinct retinal edema in the area superior to the optic disc and macula due to vascular disturbances of the superior temporal superior and superior nasal retinal arteries. The right eye was normal. Fluorescein angiography revealed recanalized arteries in the superior retinal area with conspiciously early dye filling as a paradoxical sign. Doppler sonography of the neck and orbital arteries and transesophageal echocardiography (TEE) findings were inconspicious. However, blood examination revealed an elevated thrombin-antithrombin complex and reduced free protein S., Conclusion: Coagulopathy can be a side effect of oral contraceptives. Even nowadays, women taking contraceptives risk the danger of vascular occlusions especially if the women suffers from arterial hypertension, diabetes mellitus, have a coagulation anomaly, or if she is a chronic smoker. Before treatment with oral contraceptives commences, a thorough medical examination is necessary. If the family history reveals prominent cardiovascular risk factors, testing for thrombophilia is recommended. Even nowadays, patients should be warned of the risk of visual field defects as a potential side-effect associated with oral contraceptives., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose of the Study: While evaluating radiotherapy results in patients with primary and secondary optic nerve sheath meningiomas (ONSM) treated between 1993 and 2002, a large amount of data about early signs and symptoms has been collected which might be helpful for establishing an early diagnosis., Methods: We have reviewed the charts of the patients available at the Centre of Ophthalmology, collecting especially pretreatment data., Results: 112 patients, 4 with bilateral tumours, 83 % female were included. Mean age was 51.7 years. Visual acuity loss with relative afferent pupillary defect was the main symptom and sign in primary ONSM (38 patients). Median interval between first symptoms and diagnosis was 12 months. Optic discs were in approximately one half atrophic, the other half were swollen, and only rarely normal (3 cases only). Retinociliary shunt vessels were seen in 10 cases. Nerve fibre bundle defects were the major visual field finding (including constriction and central scotoma). Visual acuity was better than 0.5 (20 / 40) in 46 % and worse than 0.1 (20 / 200) in 30 %. In secondary ONSM, the interval to diagnosis was with a median of 6 months shorter than in primary ONSM. Approximately half of the optic discs were atrophic, only 6 % were swollen. Even here nerve fibre bundle defects were dominating, only 7 % had vertical hemianopic defect. Visual acuity was better than 0.5 (20 / 40) in 30 % and in worse than 0.1 (20 / 200) 22 %. 45 % had ocular motility disorders., Discussion: Vertical hemianopic defects were surprisingly rare. The high rate of nerve fibre bundle defects and the relatively high number of patients with good visual acuity might explain why this disorder is occasionally mistaken for glaucoma. A typical clinical appearance can be outlined: mainly mid-aged women, slowly progressing visual loss, frequently motility disorders, relative afferent pupillary defect, nerve fibre bundle defects and atrophic or--mainly in primary ONSM--swollen optic disc form the characteristic picture., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Background: Patients suffering from pituitary adenomas and diseases of the chiasma typically show a bitemporal hemianopia. The residual undisturbed nasal visual fields of both eyes should have an extension of (at least) 120 degrees and are according to the actual German traffic rules (FeVAndV) for cars of the classes A, B, M, L and T. The intact half fields fit geometrically to one virtual normal field, that seems to correspond in the centre of a normal field. Reports on this problem often do not address correctly the questions of suitability for participation in road traffic., Patients: The case of a patient with typical bitemporal hemianopia illustrates the sensorial peculiarities: the functioning temporal retinal halves do not correspond. This patient suffered additionally from disturbing diplopia due to a small-angle exotropia. The extent of the performed eye muscle surgery was selected to induce a slight overcorrection, i. e., resulting in 3 to 5 degrees esotropia. This eliminated the diplopia, but resulted in a vertical scotoma of the extension of the esotropia., Conclusions: In bitemporal hemianopia the undisturbed nasal visual half fields do not add up to a "nearly normal field of one eye". Moreover, either diplopia or--much more dangerous in traffic--a central vertical scotoma is the result. The explanation for this is a sliding of the hemifields of each eye without stabilisation by corresponding areas of the retinas of the right and left eyes. The peripheral extension of the visual field is not the key to the problem to imagine how a patient with typical bitemporal hemianopia will visualise daily life and traffic. In bitemporal hemianopia there is substantially no eligibility for driving a car or motor bicycle in road traffic.

Background: Trauma of the optic chiasm has been reported but its incidence is low., Patients and Methods: Retrospective review of patients diagnosed with traumatic optic neuropathy between 1992 and 2002., Results: Among 91 patients with a diagnosis of traumatic optic neuropathy, 10 showed evidence of optic chiasm involvement. All were males, the average age was 32 years (range 22-43). Injuries resulted from a rapid deceleration in 8 cases (car or motorcycle accident or fall from a minimum height of 5 meters). Coma was present in 6 cases and neurologic disorders in 8 cases. Optic neuropathy was present in 8/10 cases. Visual improvement was noted in two patients who suffered from milder head trauma., Conclusions: Optic chiasm dysfunction following head trauma is not that rare, as 11 % of our traumatic optic neuropathy group presented such a dysfunction. In some cases the visual field defect was obvious, but in some others it was more subtle. Visual prognosis was generally poor, probably related to the the severity of the impact.

Background: The Heidenhain variant is a subtype of Creutzfeldt-Jakob disease (CJD) where visual symptoms are leading., History and Signs: We report on a 60-year-old woman who developed within a few weeks bilateral inferior hemianopsia. Morphological findings of the eyes were normal. Neurological examination and cerebral CT/MRI were normal too. P 100 latency of visual evoked potentials (VEP) of both eyes, however, was delayed., Outcome: During the course of the disease visual field narrowed progressively and 3 months after the first symptoms the patient went blind. Only at that time myoclonia, hyperkinesia, and psychiatric symptoms appeared. Changes of EEG and cerebrospinal fluid were suggestive of Creutzfeldt-Jakob disease (CJD). The patient died after 5 1/2 months and diagnosis was confirmed neuropathologically with mainly occipital spongiform encephalopathy., Conclusion: This case illustrates the diagnostic difficulties of the Heidenhain type of CJD and demonstrates that in patients with progressive visual field defects without morphological abnormalities of the eyes or radiological abnormalities of the brain CJD should be considered. It should be looked out for additional neurological (especially extrapyramidal) and psychiatric symptoms.

Introduction: Visual hallucinations or illusions are not a rare symptom. However, they are often unrecognized. Unawareness of the meaning of these symptoms often mislead both the patient and his physician., Purpose: To define and describe the types of visual illusions and hallucinations which can be commonly encountered in neuro-ophthalmological practice., Methods: Overview article., Results: Hallucinations are a perception not based on sensory input, whereas illusions are a misinterpretation of a correct sensory input. Both phenomenon can be due to medication or drug, or to an altered mental status. Visual hallucinations can be formed (objects, people) or unformed (light, geometric figures). They can be generated either by a lesion on the antechiasmatic pathway, by a seizure phenomenon, by a migrainous phenomenon, or by a release phenomenon secondary to visual differentiation. Investigations will be directed towards a retinopathy, an optic neuropathy, a chiasmal or retrochiasmal lesion, or a bilateral antechiasmal lesion (Charles Bonnet syndrome). Visual illusions include meta-morphopsias, micro- macropsias, polyopia, palinopsia (visual perseveration), achromatopsia, Pulfrich phenomenon, or subjective vertical deviation. Illusions can be due to lesions of the retina, the optic nerve, the visual cortex (primary or associative), or the graviceptive pathways., Conclusions: As most patients do not spontaneously mention their symptoms, history taking is essential. The first step is to rule out medication or an altered mental status as the possible cause of these symptoms. Then, careful visual function examination should provide a good insight in the location of the lesion.

Background: To propose a quick test using striated lens according to Bagolini for detecting quadrantanopic and hemianopic visual field defects., Patients and Methods: The results of this test are presented and compared with Goldmann perimetry in five patients suffering from quadrantanopic and hemianopic visual field defects in hypophyseal adenoma (2 x quadrantanopia, 1 x bitemporal hemianopia) and occipital process (2 x homonymous hemianopia). To examine the visual field the patient has to fixate a light at 50 cm distance. Due to the striated glasses two light stripes are generated along the 45 degrees diagonal, crossing in the fixated light in normal binocular vision. The temporal lower and nasal upper quadrants of both eyes and after switch the striated glasses around the horizontal axis, the nasal lower and temporal upper quadrant of both eyes can be tested along the 45 degrees axis. While fixating the lamp the patient is asked (in normal binocularity identical with the crossing point), if one or more of the four light stripes, beginning at the crossing point is shorter or weaker than the others, or interrupted or missing totally., Results: Shortened or absent light stripe indicating quadrantanopic visual field defect agrees with the location of visual field defect in kinetic Goldmann Perimetry. An absent light stripe indicates a complete quadrantanopia, a shortened light stripe an incomplete quadrantanopia. Fixation is warranted easily by the crossing light stripes., Conclusion: The dissociation with the aid of striated glasses allows a simultaneous test of both eyes in the 45 degrees-axis of all four quadrants in combination with the location of the visual field defect in this axis. The proposed confrontation test is a simple and quick test without extensive equipment. This test seems to be a useful tool in detecting homonymous or heteronymous quadrantanopic and hemianopic visual field defects for quick screening purposes, especially in immobile patients.

Background: Arachnoidal cysts are cystic lesions filled with a cerebrospinal-fluid-like content within the leptomeninges. Usually arachnoidal cysts represent a congenital malformation. Clinical signs (increased intracranial pressure and/or neurological defects) may become apparent in children or young adults., Patient: A sixteen year old boy was referred to our outpatient clinic because of blurred vision in both eyes since five days. The patient complained of cephalgia and of an increased sleep requirement in the last two weeks. Morphological findings were within the normal range. The visual acuity was 0.7 in the right eye and 0.2 in the left eye. The visual fields showed an incomplete homonymous hemianopia to the right. The CT and MRI revealed a retrosellar arachnoidal cyst. Two weeks after fenestration of the cyst the visual acuity had risen to 1.3 in both eyes and the visual field defects had disappeared nearly completely., Conclusion: A retrosellar arachnoidal cyst can impair the visual pathway. Early fenestration prevents permanent damage.

Background: Multifocal electroretinography allows simultaneous recording of 61 focal electroretinographic signals from the retina of the posterior pole. The function of the outer retinal layers can be mapped for a visual field of 30.5 degrees radius. We herein describe the topography of such potentials in patients with hemianopic and concentric visual field defects., Subjects and Methods: Six patients with visual field defects caused by chorioretinal and central visual pathways diseases were examined using multifocal ERG., Results: In 30 normal volunteers in the entire 30 degrees visual field clear signals were obtained. In the patients with visual field defects caused by retinal diseases in areas with reduced light sensitivity diminished electroretinographical activity was found. In contrast, in patients with bitemporal hemianopsia due to a chiasmal lesion no correlation between visual field and magnitude of focal ERGs was seen., Conclusions: In retinal disorders defects in multifocal ERG presented the similar pattern as scotomata in perimetry. The patient with visual field defects due to disturbances in the chiasma exhibited a normal ERG-topography. In patients with visual field defects multifocal ERG supported differentiation of the location of the lesion.

The authors report on a 81-year-old-lady with Charles Bonnet-syndrome. This syndrome is a special form of a visual hallucinosis, which affects typically otherwise healthy, elderly people, who mostly suffer from reduced vision. Ophthalmologic and psychiatric findings are demonstrated in detail, in particular a reduced left-occipital perfusion in this syndrome is shown with a spect (single photon computed tomography) and discussed with the published literature.

Author reports on a 82-years old man with two chronic subdural hematomas after head-trauma 4 weeks ago: one above right cerebral hemisphere with light displacement of median line, light compression of side-ventricle, too. A second one fronto-temporal above left hemisphere, smaller than the other one. Defect of visual field was the only neuro-ophthalmologic sign.

The gray scale of the Octopus neuro-ophthalmologic program N1 shows the difference between actual values and age-related normality. This permits optimal visualization of slight relative scotomas. The interpolation algorithm is computed for the four individual quadrants of the visual field, enabling either lateral hemianopic or fascicular defects to be sharply delineated. In addition, the N1 program automatically provides a global, nonsectorial gray scale which is useful for demonstrating visual defects which are not delineated by either the horizontal or the vertical meridian.

In three patients, recurrence of a large pituitary adenoma was not detectable by ophthalmological means, because the tumor recurred in an area where the optic nerve fibers had already been destroyed by the primary tumor. These cases demonstrate that unchanged visual fields do not exclude tumor regrowth, and that computer tomography is indispensable in the follow-up surgically treated pituitary adenomas.

A 65-year-old patient sustained a transient left-sided sensomotoric monoparesis with homonymous hemianopsia. One day later there was an acute deterioration in the patient's vision and he developed achromatopsia, prosopagnosia, disturbance of spatial orientation and a homonymous upper hemianopsia. Six months later the findings are about the same. The CT shows a bioccipital lesion with left-sided accentuation, extending dorsocaudally. The origin of the cerebral infarct is presumably a vertebrobasilar insufficiency due to congestive cardiomyopathy and atrial fibrillation.

The use of computed tomography (CT) simplifies neuroradiological investigations. A CT helped to confirm the diagnosis of an occipital vascular leasion in two cases of bilateral blindness.

In cases of homonymous hemianopsia, with the aid of pupillographic perimetry it is possible to differentiate between infra- or suprageniculate lesions. Principally the validity of Wernicke's theory remains unchanged. However in processes in the central visual pathways a hemihypokinesia of varying degree may be found. In the blind visual fields so far in our cases a congruence between pupillographic and perimetric thresholds has not been confirmed. The phenomenon of hemihypokinesia of the pupil is discussed.

It is reported about a 14 year old girl, sustaining an avulsion of the left eye-ball by a coat-rack. The optic nerve was cutted 18 mm retrobulbarly. In perimetry of the fellow-eye a temporo-superior defect was found as proof of traumatisation of the anterior-loop-fibers in the chiasm.

Patients with circumscribed visual field defects can perceive them while looking at a surface with small black and white spots flickering randomly at high frequency (such as the white-noise field of a TV screen following the end of transmissions for the day). This autonomous perception of scotomata can be used as a screening method, to perform subsequent manual or automatic grid perimetry with the same TV monitor, concentrating on the defective part of the visual field alone. The results of white-noise scotometry used to examine the visual fields of 161 patients are presented. It appears that the test is capable of identifying suprageniculate homonymous hemianopias, since patients either do not observe them at all in the white-noise field or only to a far lesser degree. In addition, the blind spot and some congenital visual field defects are not observed as visual field defects at all in the white-noise field. However, all acquired circumscribed defects caused by lesions of the first, second, or third neuron are readily seen in the white-noise field if the patient is capable of stable fixation.

Patients with homonymous hemianopia are quite differently handicapped in daily life. While residual visual functions in the blind hemifield can be responsible for such differences in visual orientation, compensatory oculomotor mechanisms or the presence of additional visual hemineglect may also play a role. In order to find objects in their blind hemifield such patients essentially employ three oculomotor searching strategies: A "staircase" strategy, an "overshoot" strategy, and a "predictive" strategy. Patients with additional visual hemineglect, however, are neither able to use the predictive strategy, nor can they develop an overshoot strategy with time. Oculographic criteria compiled previously by the present authors were employed in 19 cases with homonymous hemianopia and/or visual hemineglect to demonstrate the possibility of an objective and quantitative delimitation of these two disorders. The practical importance of such a delimitation is that patients with hemineglect are much more handicapped, but ignore or underestimate their handicap.

Multiple ischemic lesions of the optic pathways may cause a number of complex visual field defects; their analysis is of substantial diagnostic significance, especially if the computer tomogram is negative. Perimetry is often complicated by an accompanying organic psychosyndrome.