CASE OF THE MONTH

Patient Profile
AGE

84 year old

Gender

Male

Last
Eye Exam

January 2020

Current
Rx

OD: plano-0.75 x 065 +2.50
OS: -0.75-1.00 x 070 +2.50

Medical
History

Brain Cancer 2014
Lasik Vision Correction 2000
Cataracts Removed in Both Eyes

Chief
Complaint

Unhappy with near vision

Uncorrected
Visual Distance

OD 20/40
OS 20/50

EXAM PROTOCOL

While reviewing the refraction, we discussed the benefits of contrast in relationship to both near vision and golfing. Specifically, we discussed the benefits of good lighting when reading paper and high contrast when working on screens. With golfing, a bright neon golf ball would improve contrast making it easier to follow. Regarding his ocular health, chair side testing revealed testing within normal limits for his extraocular muscles, confrontations, and color vision. Stereopsis testing was slightly reduced, which aligns with the reduced visual acuity. Anterior segment evaluation performed with Eyefficient Firefly S390L digital slit lamp. The visual fields were performed OCULUS Easyfield C. His visual field was significant for a right congruous homonymous hemianopia. Although the reliability of his visual fields is questionable, a repeat was not warranted due to age, poor mobility, and poor acuity. Furthermore, the findings aligned with a history of brain surgery. The anterior ocular evaluation on the Eyefficient Firefly S390L digital slit lamp was significant for dermatochalasis OU and IOL placement OU. Otherwise, all other anterior segments were unremarkable and within normal limits. IOP by NCT was deferred at the time of examination secondary to COVID-19. Posterior segment photos were attempted, but due to poor patient compliance interpretation was limited. While educating the patient on today’s examination findings, he was aware of his visual field defect from everyday experiences; however, it was unclear if it was ever made a formal clinical finding or diagnosis. A further ocular health examination was also recommended to account for his overall reduced visual acuity and ensure good posterior segment health. During that evaluation, the right homonymous hemianopsia should also be confirmed with a Humphrey 24-2.

CONCLUSION

The patient was diagnosed with a right homonymous defect. There were no other afferent findings, which makes sense because the lesion would be behind the Lateral Geniculate Nucleus. Due to its high congruity, it most likely is in the region of the optic tract. The second most likely area would be the left occipital lobe both above and below the calcarine fissure. This information is imperative to pass on to his neurologist, because if this does not match with his medical and surgical history, then it would be warranted to resume a narrowed search for the recurrence of his brain cancer. The appropriate paperwork was provided to the patient, but no follow-up has been received.

PHOTOS

EXAM EQUIPMENT
  • Centervue DRS
  • Oculus Easyfield C
  • Eyefficient Firefly S390L
  • 2020Now Eyelogic X2 Refraction System
  • Topcon CV.5000Phoropter
  • Visionix VX120