clinical

Susie Luu
Andrew W Lee
Andrew Daly
Celia S Chen

Visual field defects

after stroke
A practical guide for GPs

Background
Visual field defect after stroke can result in significant disability and reduction in quality
of life. Visual rehabilitation aims to maximise the residual vision and decrease functional
disability. Understanding the rehabilitation options available, and where to refer
patients with visual defects after a stroke, can help patients, and their families, in the
rehabilitation process.

Objective
This article provides a review of the functional disability from visual field loss and
discusses the various forms of visual rehabilitation.

Discussion
Optical therapy, eye movement therapy and visual field restitution are the rehabilitation
therapies currently available. Rehabilitation needs to cater to each patients specific
needs. Any patient recognised as having a visual field defect after stroke needs prompt
referral for further assessment and consideration for visual rehabilitation.
Keywords: homonymous hemianopia; stroke; visual fields; hemianopia/therapy;
rehabilitation/methods

Stroke is the third most common cause

of death after heart disease and cancer,
with 48 000 new cases each year.1 More
than three out of four stroke sufferers
report some form of disability, of which
visual impairment is becoming more
recognised. Approximately 16% of these
have a homonymous visual field defect
poststroke.2

A homonymous visual field defect is defined as
a loss of part of the field of vision as a result of
interruption of the visual pathways distal to the
optic chiasm. A stroke patient may be unaware
of their field defect and thus engage in activities
such as driving, where such a field defect could
have deleterious outcomes.

Visual field loss: location and

types
The most common type of visual field loss is a
complete homonymous hemianopia (HH). This
occurs in approximately 8% of all strokes.3
Homonymous hemianopia is a loss of the right
or left halves of the visual field of both eyes
(Figure 1a, 1b) and usually occurs as a result of
a middle cerebral or posterior cerebral artery
stroke affecting either the optic radiation or
visual cortex of the occipital lobe (Figure 2). The
tip of the occipital lobe may receive a dual blood
supply from both the posterior cerebral artery
and end arteries of the middle cerebral artery,
and thus the central or macular portion of the
visual field of the patient may not be affected,
resulting in an HH with macular sparing (Figure
1c, Figure 2).
A superior quadrantanopia results from an
insult to the optic radiation inferiorly in the
temporal lobe, resulting in a pie in the sky
type of visual field defect (Figure 1d), while an
inferior quadrantanopia is caused by damage
to the parietal lobe optic radiation (Figure 1e).
The quadrantanopia can also be complete or
incomplete depending on the extent of the
involvement of the optic radiation. In general,
a homonymous quadrantanopia is less
functionally debilitating.
Zhang et al4 analysed the location of
homonymous field defect in stroke and found
the majority (54%) were occipital lobe lesions,
followed by optic radiation (33%), optic tract
(6%), multiple sites (5%), and lateral geniculate
body (1%).

Visual field loss after stroke

Spontaneous visual field improvement can occur
poststroke but in varying degrees. This has

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clinical Visual field defects after stroke a practical guide for GPs

been reported in up to 50% of patients, usually

within the first 36 months. After this period
spontaneous recovery is possible, but usually at
a much slower rate.5

Impact
Visual field loss following a stroke can interfere
with an individuals ability to perform activities
of daily living and threaten the ability to live

Figure 1. Visual field defects seen in each

eyes visual field and the image perceived
by the patient: a) right HH; b) left HH; c) left
HH with macular sparing; d) right superior
quadrantanopia, pie in the sky; e) inferior
quadrantanopia pie on the floor

independently. The impact of visual impairment

can be wide ranging. Impact on functional
performance can include a general reduction in
mobility, a reduced ability to judge distance and
impaired stereovision. An immediate consequence
is a higher risk of falls due to bumping into objects
on the side of impaired vision.6 It is important
to diagnose visual field impairment, particularly
in the elderly population, to prevent further
poststroke injury from falls.7
Hemianopic alexia is a term used for specific
patterns of reading deficit caused by focal brain
injury, usually a stroke, often affecting the left
hemisphere. Reading involves using the righthand side of a word to help plan reading eye
movements across the line of the text. A right
HH and resulting hemianopic alexia results in
deficiencies in this process with insufficient eye
movements and text reading. Reading impairment
poststroke is commonly reported and can be
severely debilitating.8
Using a vision specific quality of life
questionnaire, Chen et al9 noted that the
presence of an HH was associated with
reduced quality of life as measured by vision
specific social functioning, mental health and
dependency. These may in turn be associated

with a loss of confidence, depression and

reduced quality of life.10
There is a significant effect of a complete
hemianopia on a persons peripheral vision and
driving. Patients may pose a risk to themselves
and the general public if they have a poststroke
visual field defect and continue to drive. It is
important that all GPs are aware of the current
guidelines regarding fitness to drive.

Associated visual disabilities

Visual neglect is a spatial inattention to one side of
the body. It is commonly caused by a defect in the
dominant parietal lobe commonly the left parietal
lobe.11 Visual neglect can occur with or without
a homonymous visual field defect. However, due
to the visual neglect, the person cannot learn to
compensate because they cannot mentally attend
to that side. A man with visual neglect may only
shave one side of his face. A left visual neglect
patient, when asked to recall a description of a well
known area, will fail to mention the things to their
left side. Visual neglect usually indicates a worse
prognosis for recovery and these patients usually
benefit from occupational therapy to learn to attend
the affected side.
It is also common for visual field loss to be
associated with abnormal eye movements as
there are frontal and parietal eye fields that help
initiate and modulate a saccade movement to
initiate look to one side and maintain the gaze
at a position. There may be impaired fast eye
movements to the side of impaired vision which
contribute to reading difficulties.12

Legal driving requirement

The National Transport Commissions minimum
medical standards for vision for driving in
Australia13 in regards to visual acuity and visual
fields are Snellen visual acuity of 6/12 or better
in the better eye or with both eyes together, with
maximal correction (with glasses if necessary)
and on automated static perimetery, binocular
visual field must have a horizontal extent of at
least 120 degrees with 10 degrees above and
below the horizontal midline.

Screening for neurological

visual loss
Figure 2. Neuroanatomy of the visual pathway and the blood supply. Lesions at a particular site
of the visual pathway result in a specific visual field defect depicted on the right hand side

500 Reprinted from Australian Family Physician Vol. 39, No. 7, JULY 2010

In the general practice setting, screening for

neurological visual field loss is performed by

Visual field defects after stroke a practical guide for GPs clinical

confrontation testing. The examiner should sit

approximately 1 metre from the patient, directly
in front and facing the patient. It is first performed
with both the patients eyes open to detect if the
defect is homonymous (ie. present with both eyes
open). The examiner holds out fingers on the left
and right superior quadrant simultaneously and
asks how many fingers are being held up. It is
advisable to use one, two or five fingers as three
and four fingers are easy to confuse. It is also
advisable to have different numbers of fingers
on each of the two hands (eg. one on the right
hand side and two on the left hand side) to detect
which side the patient is missing. Repeat the same
process in the inferior quadrants. This quickly
delineates if there is a homonymous lesion with
omission of one side with both eyes open and also
determines if it is a hemianopia or quadrantanopia.
After this, test each eye individually with finger
counting in the four quadrants.
To better delineate the degree of field loss
and to detect if the defect is macular sparing, the
patient is asked to look at a central fixation such
as the examiners nose. Test one eye at a time by
covering the contralateral eye and move a red pin
from the peripheral towards the centre in eight
directions (superior, superior temporal, temporal,
inferior temporal, inferior, inferior nasal, nasal and
superior nasal) and ask the patient to say yes as
soon as they see the red pin.
Part of the problem of the visual field
confrontation test is that it may underestimate the
degree of field loss.2,14 It is therefore important to
refer for formal visual field testing those patients
with suspected visual field loss (Figure 3). The
ophthalmologist can help assess the visual field
loss using automated perimetry.
To assist driving eligibility, binocular visual
field testing is done using an automated perimetry
program called an Esterman visual field. Ability
to see the central 120 x 10 degrees without more
than two continuous spots missing satisfies the
driving visual field criteria. Some patients with
incomplete quadrantanopia or selected patients
with incomplete HH with macular sparing may still
achieve the binocular field for driving.

Rehabilitating homonymous
visual field loss
The aim of rehabilitation is to improve awareness
of the area of visual field loss and to employ

strategies to promote the patients ability

to scan in the area of the defect. Current
rehabilitation strategies for HH are based
on several different theories and the three
main approaches (eye movement therapy,
optical therapy, and visual field restitution) are
described in more detail below.15,16

Eye movement therapy

Most of the vision rehabilitation therapy
offered in Australia is based on eye
movement therapy, also known as
compensatory or visual search training.
Eye movement therapy improves visual
performance by regulating the eye
movements. This encompasses improving
awareness of the visual field loss and
employing visual search strategies to
promote the individuals ability to scan to the
impaired side.
Patients with HH involuntarily
compensate by making extra saccades,
ie. increased eye movement towards
the hemianopic field, particularly during
tasks such as reading or scanning.
Unfortunately, for the majority of patients,
these compensatory eye movements are
disorganised, resulting in longer search times
and inappropriately increased fixation.17 This
can result in problems with reading as a result
of an inability to generate efficient reading
saccades across static text. Eye movement
therapy or scanning therapy helps patients
practice large saccades into the hemianopic
field, which improves visual search in this area.
The eye movements move from large oculomotor
movement to fine saccadic eye movement to help
reading text moving horizontally which induces a
small field optokinetic nystagmus. Eye movement
therapies improve visual search response times
and saccade efficiency. Training over multiple
sessions is required.
Each of the rehabilitation service agencies
offer slightly different forms of eye movement
based therapy. At present, the eye movement
therapy is subjective and negotiated between
the therapist and patient. There are some
structured training of saccadic movements on
a standardised computer screen followed by
mobility training. Training of oculomotor or
saccadic movements has been demonstrated

Figure 3. An automated perimetry printout using

a SITA 302 strategy to test the central 30 degree
visual field of each eye. The printout is placed
with the right visual field on the right side and
similarly on the left, as if seen by a patient: a)
the reliability indices to show if there are fixation
losses during the testing; b) the grey scale as a
gross visual representation of the area and extent
of the visual loss. This patient had an inferior
quadrantanopia on confrontation testing but on
automated perimetry, an incomplete HH, denser
inferiorly than superiorly; c) the pattern deviation
which is the plot commonly interpreted by
ophthalmologists. The pattern deviation compares
the deviation of the patient to someone of the
same age and plots out focal areas of relatively
greater visual field loss, hence is a more sensitive
plot to show degree of abnormality compared to
the grey scale

to lead to an improved visual search field and

reading ability.1821

Optical therapy
Optical therapies aim to expand the visual field
using optical aides such as prisms, mirror lens
or telescopes. Prisms are often used and are
placed on the spectacle lens of either one or
both eyes, causing distortion and displacing
images from the hemianopic field across into
the seeing side. Patients may then use head
turning and eye movements to view the objects
of interest on the affected side. The acceptance
rate is variable with some patients discontinuing
the prism glasses due to inadaptability to
distortion and image jump. On the other hand
some patients report an improvement in their
visual fields, with a potential to expand the
visual field by up to 20 degrees.22

Visual field restitution

Visual restorative therapy includes flicker
stimulation of the blind field, which produces
changes in cortical function with cortical

Reprinted from Australian Family Physician Vol. 39, No. 7, JULY 2010 501

clinical Visual field defects after stroke a practical guide for GPs

reorganisation.23 It is based on the theory that

training reactivates surviving neurons of the
partially damaged area of the brain and thus
restores visual function. Patients practice
detecting simple stimuli (eg. small circular lights)
presented in the area of the damaged visual field
or at the border of the field defect.
Visual field restitution is usually carried
out using a commercialised computer based
program via a laptop at 30 cm, patients perform
2 x 30 minute sessions per day, 6 days a week
for 6 months. Each month, performance data is
reviewed and the patient is sent a new program
based on their performance. Treatment results
remain controversial and when improvements
in the affected visual field are seen, it is
uncertain whether the improvements are due
to neuroplasticity or to microsaccadic eye
movements.24,25 Visual restitution therapy is
currently not available in Australia.

Vision rehabilitation services

In every state in Australia there are agencies
that offer vision rehabilitation (Table 1), or that
offer community services such as orientation and
mobility training, that would benefit people with
neurological vision loss. Some agencies offer a

multidisciplinary assessment in a low vision clinic

comprised of an ophthalmologist, an optometrist
and an occupational therapist/counsellor. The
ophthalmologist and optometrist help confirm
the diagnosis and define the extent of the visual
field defect and loss, as well as provide refraction
or aids to maximise vision. The occupational
therapist/counsellor can help define the area of
vision most troublesome to the person and advise
appropriate management such as counselling or
visual aids. In selected patients who wish to use
optical devices, an orthoptist is involved in the
assessment for prism fitting and training. Vision
rehabilitation for neurological vision loss is usually
provided by an occupational therapist in the context
of community services for orientation and mobility
as well as independent living. Other community
services provided by agencies may include leisure
with services such as audio books to help with
reading difficulties as described above. Referrals
can be made directly to the services.

Summary of important points

Visual field defects poststroke affect activities
of daily living including mobility, reading and
driving.
Recognising patients with visual field

Table 1. Australian vision rehabilitation services for neurological vision loss

defects after stroke is important as visual

rehabilitation may help retain independence
and improve quality of life.
It is important to diagnose visual field
impairment, particularly in the elderly
population to prevent further injury poststroke
from falls.
Patients with HH should be referred to a low
vision centre for further assessment and
consideration of visual rehabilitation.
Visual rehabilitation therapies need to be
individualised and tailored to the specific
needs of each patient.
The current legal driving criteria is a best
corrected visual acuity of 6/12 or better
and a binocular visual field of 120 degrees
horizontally and 10 degrees vertically.

Authors

Susie Luu MBBS, MPH, is an ophthalmology

resident, Department of Ophthalmology, Royal
Adelaide Hosptial, South Australia. suseluu@
yahoo.com.au
Andrew W Lee MBBS, MPH, FRACP, is a neurologist, Flinders Comprehensive Stroke Centre,
Flinders Medical Centre, Adelaide, South
Australia
Andrew Daly BEc, ACA, FAIM, JP, is Executive
Director, Royal Society for the Blind Inc, Adelaide,
South Australia

State

Agency

Website

South Australia

Royal Society for the Blind

www.rsb.org.au

Celia S Chen MBBS, MPHC, FRANZCO, is a

neuro-ophthalmologist, Department of
Ophthalmology, Flinders Medical Centre and
Flinders University, Adelaide, South Australia.

Guide Dogs SA.NT

www.guidedogs.org.au

Conflict of interest: none declared.

Guide Dogs NSW/ACT

www.guidedogs.com.au

Vision Australia

www.visionaustralia.org

Guide Dogs SA.NT

www.guidedogs.org.au

Vision Australia

www.visionaustralia.org

Guide Dogs Victoria

www.guidedogsvictoria.com.au

We would like to thank David Heinrich for his

artwork on the medical illustration and Margaret
Brown and Annette Thompson, of the Royal
Society for the Blind Inc., South Australia, who
have been providing excellent support for patients
with neurological vision loss.

Vision Australia

www.visionaustralia.org

References

Guide Dogs Queensland

www.guidedogsqld.com.au

Vision Australia Queensland

www.visionaustralia.org

Australian Capital
Territory

Vision Australia Canberra

www.visionaustralia.org

Tasmania

Guide Dogs Tasmania

www.guidedogstas.com.au

Vision Australia Tasmania

www.visionaustralia.org

Association for the Blind of WA

www.abwa.asn.au

New South Wales

Northern Territory

Victoria

Queensland

Western Australia

502 Reprinted from Australian Family Physician Vol. 39, No. 7, JULY 2010

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