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Endgames Picture Quiz

Visual impairment

BMJ 2013; 346 doi: (Published 10 April 2013) Cite this as: BMJ 2013;346:f2163

This article has a correction. Please see:

  1. Ramachandiran Nandhagopal, consultant neurologist
  1. 1Department of Medicine, College of Medicine and Health Sciences, Al-Khod, Zip 123, Muscat, Oman
  1. Correspondence to: R Nandhagopal rnandagopal{at}

A 66 year old man with diabetes presented to the emergency service six hours after the acute onset of visual loss in his left eye. Figure 1 shows the only neurological deficit that was elicited during bedside clinical examination. Serial electrocardiography showed an intermittent fast rhythm (which lasted for several hours), characterised by varying R-R intervals and absence of P waves, followed by a return to sinus rhythm. Cranial magnetic resonance imaging showed an area of infarction with haemorrhagic transformation. His medical history included episodes of palpitation and dizziness, for which he received a diagnosis of non-valvular atrial fibrillation.

Fig 1 Schematic representation of the clinical findings seen during bedside finger perimetry. OD=right visual field; OS=left visual field


  • 1 What clinical finding is depicted in fig 1?

  • 2 On the basis of the clinical sign seen in fig 1, can you localise the lesion (infarct)?

  • 3 How would you prevent recurrence of this patient’s new neurological symptoms?


1 What clinical finding is depicted in fig 1?

Short answer

Left homonymous superior quadrantanopia.

Long answer

Figure 1 shows a visual field defect (visual loss) in the right superior nasal quadrant and left superior temporal quadrant. Hence, the patient had left homonymous superior quadrantanopia. Although the quadrantanopic visual deficit was present on either side, the patient reported visual loss in the left eye only (the eye with the temporal visual field cut). This is the usual pattern of symptoms reported by patients with homonymous quadrantanopia or hemianopia.1 In other words, patients usually project the visual loss unilaterally to the eye with the temporal field cut. Hence, while examining the visual field, careful attention should be paid to the unrecognised visual defect (not verbalised by the patient) in the …

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