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The Optic Pathway

By James Garrity, MD, Whitney and Betty MacMillan Professor of Ophthalmology, Mayo Clinic College of Medicine

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The optic pathway includes the retina, optic nerve, optic chiasm, optic radiations, and occipital cortex (see Figure: Higher visual pathways—lesion sites and corresponding visual field defects.). Damage along the optic pathway causes a variety of visual field defects. The type of field defect can help localize the lesion (see Table: Types of Field Defects).

Higher visual pathways—lesion sites and corresponding visual field defects.

With retrochiasmal lesions, visual field defects become more symmetric (congruous), as shown with the occipital lesion in #4.

Types of Field Defects

Type*

Description

Causes

Altitudinal field defect

Loss of all or part of the superior or inferior half of the visual field; does not cross the horizontal median

More common: Ischemic optic neuropathy, hemibranch retinal artery occlusion, retinal detachment

Less common: Glaucoma, optic nerve or chiasmal lesion, optic nerve coloboma

Arcuate scotoma

A small, bow-shaped (arcuate) visual field defect that follows the arcuate pattern of the retinal nerve fibers; does not cross the horizontal median

Damage to ganglion cells that feed into a particular part of the optic nerve head

More common: Glaucoma

Less common: Ischemic optic neuropathy (usually nonarteritic), optic disk drusen, high myopia

Binasal field defect (uncommon)

Loss of all or part of the medial half of both visual fields; does not cross the vertical median

More common: Glaucoma, bitemporal retinal disease (eg, retinitis pigmentosa), nonphysiologic vision loss

Rare: Bilateral occipital disease, tumor or aneurysm compressing both optic nerves

Bitemporal hemianopia

Loss of all or part of the lateral half of both visual fields; does not cross the vertical median

More common: Chiasmal lesion (eg, pituitary adenoma, meningioma, craniopharyngioma, aneurysm, glioma)

Less common: Tilted optic disks

Rare: Nasal retinitis pigmentosa

Blind-spot enlargement

Enlargement of the normal blind spot at the optic nerve head

Papilledema, optic nerve drusen, optic nerve coloboma, myelinated nerve fibers at the optic disk, drugs, myopic disk with a crescent

Central scotoma

A loss of visual function in the middle of the visual field

Macular disease, optic neuropathy (eg, ischemic or Leber hereditary neuropathy, optic neuritis-multiple sclerosis), optic atrophy (eg, due to tumor compressing the nerve or toxic-metabolic disorders)

Constriction of the peripheral fields, leaving only a small residual central field

Loss of the outer part of the entire visual field in one or both eyes

Glaucoma, retinitis pigmentosa or another peripheral retinal disorder, chronic papilledema, following panretinal photocoagulation, central retinal artery occlusion with cilioretinal artery sparing, bilateral occipital lobe infarction with macular sparing, nonphysiologic vision loss, carcinoma-associated retinopathy

Rare: Drugs

Homonymous hemianopia

Loss of part or all of the left half or right half of both visual fields; does not cross the vertical median

Optic tract or lateral geniculate body lesion; lesion in temporal, parietal, or occipital lobe (more commonly, stroke or tumor; less commonly, aneurysm or trauma); migraine (which may cause transient homonymous hemianopia)

*Migraine can cause various visual field defects, although it most commonly causes transient homonymous hemianopia.

Adapted from Rhee DJ, Pyfer MF: The Wills Eye Manual, ed. 3. Philadelphia, Lippincott Williams & Wilkins, 1999.

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