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Homonymous Hemianopia With Normal Neuroimaging

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 46-year-old man presented with a 2-week history of a persistent blurred area in his right lower visual field of both eyes. He noticed colors surrounding the dark area that lasted 2 to 3 minutes at a time and occurred multiple times per day. His medical history was significant for dyslipidemia for which he took rosuvastatin. He also reported feeling lethargic, with polydipsia and a dull mild holocephalic headache during this period. Ophthalmological examination revealed a visual acuity of 20/20 OU, pupils were equal and reactive to light with no relative afferent pupillary defect, and color vision was normal. Dilated fundus examination was normal. Humphrey 24-2 Swedish interactive threshold algorithm fast visual field testing revealed a right homonymous hemianopia denser inferiorly (Figure, A). An urgent noncontrast computed tomography (CT) scan of the head was obtained and was normal (Figure, B). Magnetic resonance imaging (MRI) of the brain was initially reported as normal but revealed subtle abnormal T2/fluid-attenuated inversion recovery hyperintensity involving the left occipital cortex after further review (Figure, B).

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A 46-year-old man presented with a 2-week history of a persistent blurred area in his right lower visual field of both eyes. He noticed colors surrounding the dark area that lasted 2 to 3 minutes at a time and occurred multiple times per day. His medical history was significant for dyslipidemia for which he took rosuvastatin. He also reported feeling lethargic, with polydipsia and a dull mild holocephalic headache during this period. Ophthalmological examination revealed a visual acuity of 20/20 OU, pupils were equal and reactive to light with no relative afferent pupillary defect, and color vision was normal. Dilated fundus examination was normal. Humphrey 24-2 Swedish interactive threshold algorithm fast visual field testing revealed a right homonymous hemianopia denser inferiorly (Figure, A). An urgent noncontrast computed tomography (CT) scan of the head was obtained and was normal (Figure, B). Magnetic resonance imaging (MRI) of the brain was initially reported as normal but revealed subtle abnormal T2/fluid-attenuated inversion recovery hyperintensity involving the left occipital cortex after further review (Figure, B).

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Article Information

Corresponding Author: Jonathan A. Micieli, MD, CM, Kensington Vision and Research Centre, 340 College St, Ste 501, Toronto, ON M5T 3A9, Canada (jonathanmicieli@gmail.com).

Published Online: November 4, 2021. doi:10.1001/jamaophthalmol.2021.3356

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Lavin  PJ .  Hyperglycemic hemianopia: a reversible complication of non-ketotic hyperglycemia.   Neurology. 2005;65(4):616-619. doi:10.1212/01.wnl.0000173064.80826.b8PubMedGoogle ScholarCrossref
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Raghavendra  S , Ashalatha  R , Thomas  SV , Kesavadas  C .  Focal neuronal loss, reversible subcortical focal T2 hypointensity in seizures with a nonketotic hyperglycemic hyperosmolar state.   Neuroradiology. 2007;49(4):299-305. doi:10.1007/s00234-006-0189-6PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

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