63-year-old female presents as referral for bitemporal visual field defect OU
Past medical history significant for type 2 diabetes, hypertension, gout
Past ocular history significant for glaucoma suspect, ptosis, and dry eye syndrome
Review of systems negative for headaches, nausea, vomiting, fevers, or weight loss
Exam Findings
BCVA 20/20 OU, IOP WNL, P RR no RAPD. EOMI OU
Color plates full OU
Slit lamp exam: Absent tear lake bilaterally, otherwise WNL
DFE: CDR 0.7, sharp and pink OU, otherwise WNL
Figure 1: HVF 24-2 over the course of 1-2 years displayed above. Findings significant for a new, sudden onset dense bitemporal field defect.
Differential Diagnosis
Most common
Pituitary adenoma
Macroadenoma
Secretory vs non-secretory
Sphenoid or parasellar meningioma
Craniopharyngioma*
ICA Aneurysm (parasellar)
Other possibilities
Chiasmal optic neuritis
Infectious or demyelinating
Chiasmal glioma, Pinealoma*
Kids
Abscess
Metastatic lesion
Additional Investigations
OCT MAC/RNFL/GCC all WNL
Prior to ordering an MRI, repeat visual fields were obtained
Figure 2: The bitemporal field was no longer noted.
Diagnosis
Dry Eye Syndrome
Pathophysiology
Given the rapid, sudden nature of the field loss and normal repeat fields, the suspicion for a true central lesion is very low
Dry eye syndrome can manifest in a variety of ways on visual field testing, and can mimic defects resembling glaucoma, central lesions, and many others.
There are many extrinsic factors and ocular findings that may cause perimetry defects that are not secondary to true pathology. These include:
Anatomical features
Blepharoptosis
Artificial eyelashes
Tilted disc syndrome
Cataract (PSC>NSC)
Corneal opacities (scar, SPK/dry eye)
Non-organic/Functional causes
Extrinsic factors
Pupil size
Refractive error
Rim artifact
Multifocal IOL
Patient learning or fatigue
Proper technician involvement
Examples:
Figure 3A: HVF 24-2 illustrating an inferior arcuate and inferior nasal step which were actually due to lens rim artifact, as these defects resolved with lens adjustment and repeat testing.Figure 3B: Dermatochalasis causing bitemporal field defects concerning for a central lesion, namely a sellar mass. These patients had MRI’s to rule out such pathology.Figure 3C: Tilted disc syndrome is a congenital, non-hereditary syndrome associated with high myopia, and is comprised of bilateral optic disc tilting, situs inversus of the major retinal vessels, and visual field defects- most commonly superior and/or temporal. Visual field defects associated with tilted disc syndrome may show great improvement with refractive correction during testing.Figure 3D: Toxic optic neuropathy due to a variety of medications (above, ethambutol. Osaquona et al 2014) can also mimic bitemporal field loss, though toxometabolic insults typically result in cecocentral scotomas.
Summary Points
Surgical excision
References
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