BritishJournal ofOphthalmology 1993; 77:424-427

Monocular temporal hemianopia

Seymour A Hershenfeld, James A Sharpe

AbstractMonoculartemporal hemianopiawas identifiedin 24 patients. The field of the fellow eye wasnormal. Computed tomography or magneticresonance imaging showed juxtaseliar lesionsin 19 patients. Fifteen had pituitary adenomas,two had tuberculum selia meningiomas, one acraniopharyngioma, and one an astrocytoma.One patient had optic neuritis. A relativeafferent pupillary defect (RAPD) was detectedin most patients. Field loss was functional intwo. Two had congenital optic disc dysversionwith hemianopia which did not respect thevertical meridian. Monocular temporalhemianopia is attributed to involvement of theipsilateral optic nerve close enough to thechiasm to selectively impair conduction incrossing nasal retinal fibres from the ipsilateraleye, but too anterior to affect crossing nasalretinal fibres from the contralateral eye. Thecombination of an RAPD, with or withoutoptic disc pallor, on the side of monoculartemporal field loss implicates compression of

Neuro-Ophthalmology the optic nerve at its junction with the chiasm.Neurology and (BrJ7 Ophthalmol 1993; 77: 424-427)Department ofOphthalmology, TheToronto Hospital, At the optic chiasm axons from ganglion cells of

Canada the nasal and temporal retina separate, the nasalS A Hershenfeld retinal fibres crossing in the chiasm to theJ A Sharpe contralateral optic tract and the temporal retinal

Dr J A Sharpe, The Toronto fibres coursing through the lateral chiasm to theHospital, 399 Bathurst Street, ipsilateral optic tract. Compression or infiltra-Suite ECW 6-022, Toronto, tion of the chiasm causes several characteristicAccepted for publication patterns of visual field loss. By interrupting the24 February 1993 crossing nasal fibres chiasmal lesions typically

Table I Summary ofclinical information

Interval betzweenpresentation and Visual acuity

Patient and detection ofmonocular Side ofdiagnosis* Age Sex hemianopia Right Left hemianopia

1 Pit 31 M 1 month 20/20 20/20 L2 Pit 50 M 0 20/80 20/20 R3 Pit 66 M 0 20/20 20/20 R4 Pit 28 M 0 20/20 20/20 L5 Cr 40 F 1 month post-op 20/30 20/400 L6 Pit 61 F 12 months post-op 20/40 20/50 R7Dys 60 F 0 20/20 20/20 L8 Pit 46 M 0 20/20 CF L9 Pit 48 M 15 yrs post-op 20/20-3 20/20-3 L10 Pit 56 F 8 yrs post-op CF 20/20 R11 Pit 44 M 0 20/20 20/20 L12 Pit 56 F 11 yrs post-op 20/20 20/25 L13 Pit 47 F 0 20/20 20/20 L14 Pit 47 F 0 20/25 20/30 R15 Pit 42 F 0 20/25 20/70 L16 Fct 43 F 0 20/20 20/20 R17 Dys 49 F 0 20/400 20/20-3 R18 Pit 54 F 24 months post-op 20/30 20/30 R19 Pit 41 F 1 week post-op 20/25 20/25 L20 Men 33 F 0 20/50 20/20 R21 Men 57 F 0 20/60 20/20 R22 Fct 41 F 0 20/20 20/20 R23 Ast 17 M 0 20/25 20/20 R24 On 19 F 0 20/20 20/25 L

*Pit=pituitary adenoma; Cr=craniopharyngioma; On=optic neuritis; Men=tuberculum sellameningioma; Fct=functional; Dys=optic disc dysversion; Ast=astrocytoma.

cause binocular temporal hemianopic visual fielddefects aligned along the vertical meridian.' 3Anterior parachiasmal masses that compress oneoptic nerve and the chiasm cause a junctionalscotoma, consisting of an ipsilateral centralscotoma and a superotemporal field defect in theopposite eye. Masses beneath the chiasm causefield defects that are usually denser superiorly.Paracentral bitemporal hemianopia has beenattributed to posterior chiasmal compression. AAn incongruous homonymous hemianopiasignifies optic tract involvement, while decreaseof visual acuity associated with homonymoushemianopia implicates posterior chiasmalinvolvement."l Occasionally arcuate hemianopicscotoma in the temporal field are associated withdisease of the chiasm.1 5

Monocular temporal hemianopia'" can be afunctional disorder>" or a manifestation ofchiasmal compression."8 We report monoculartemporal hemianopic defects in 24 patients. Thefield of the fellow eyes was normal in each case.The clinical features and pathophysiology of thisdistinctive pattern of field loss are discussed.

Patients and methodsTwenty four patients examined over 15 years inthe neuro-ophthalmology unit of The TorontoHospital, had monocular temporal hemianopicvisual field defects. They had computed tomo-graphy (CT) or magnetic resonance imaging(MRI) of the suprasellar region and optic nerves.Appropriate endocrine studies were carried out.Visual fields were tested by confrontation,tangent screen examination, Perimetron auto-mated projection perimeter, Goldmann peri-meter, or automated perimetry with an AllerganHumphrey machine. Fields were tested seriallyfor periods ranging from 1 month to 15 years(mean 4* 1 years).

ResultsAll monocular hemianopias were superiortemporal visual field defects or involved both theupper and lower temporal field. Clinical featuresin the 24 patients are listed in Table 1. Sixteen ofthe patients had monocular hemianopia at thetime of presentation. In eight patients monoculartemporal hemianopia was detected during followup examinations 1 week to 15 years (mean 4-6years) after treatment of their suprasellardisease.

Visual acuities in the eyes with the monoculartemporal defect were typically good, but variedfrom 20/20 to finger counting, indicatinginvolvement of the nasal central field (Table 1).Sixteen patients had visual acuity 20/40 or better.Twelve of the 24 patients had right monoculardefects. Goldmann or Humphrey perimetry wasperformed on 23 patients. One patient with optic

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Monocular temporal hemianopia

3/1 000 WTO

F No HM

100 0WTOFigure I Monocularfield defect on tangent screen in a patient with a tuberculum sellameningioma. HM, hand movements; WTO, white test object.

disc dysversion had tangent screen examinationonly. Twenty two patients showed monoculardefects on tangent screen examination (Fig 1).Six of these with a monocular defect on carefultangent screen examination performed by one ofus, proved to have binocular defects on auto-mated perimetry. Ofthese six patients, three hadbitemporal defects, two showed arcuate hemi-anopic defects in the fellow eye, and one had a

junctional scotoma on Humphrey field testing.Two of these six patients showed monoculardefects on both Goldmann perimetry (Fig 2) andtangent screen examination that later proved tobe bitemporal on Humphrey field testing.Twelve patients had follow up perimetry on

the Humphrey machine; four had defects in thefellow eye, indicating that automated static peri-metry identified defects undetected by kinetictechniques on tangent or Goldmann perimetry.On the other hand detection of monoculartemporal field loss, by Humphrey perimetry(Fig 3) as the only defect in eight patients,confirmed the persistence of genuine monoculartemporal hemianopia and the sensitivity ofkinetic perimetry.Two patients had optic disc dysversion associ-

ated with a monocular defect that did not respectthe vertical midline; it sloped into the upper

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Figure 2 Goldmann visualfield in patient I5years after transcranial removal ofchromophobeadenoma ofpituitary gland, shows temporal hemianopic scotoma and upper temporal step defectin left eye.

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nasal field, resulting in a monocular pseudo-temporal hemianopia (Fig 4).Funduscopy showed optic disc pallor in the

eye with the monocular defect in 13 of the 24patients, normal discs in nine, and disc dysver-sion in two (Fig 5). Three patients had normalappearing optic discs, but they had a relativeafferent pupillary defect (RAPD), estimatedclinically, on the side of the monocular field loss.Three other patients had bilateral optic discpallor and they had RAPD on the same side asthe monocular temporal defect. There was anRAPD in 18 patients, all on the side of themonocular visual field defect. Six patientshad normal pupils. Of these six cases one hadbitemporal field defects before surgical resectionof a pituitary adenoma, but only monocular losson Goldmann perimetry after surgery; two hadfield loss in the fellow eye whichwas only detectedlater on automated perimetry; one patient hadoptic disc dysversion; and two were functional.

Pituitary adenoma was the cause ofmonocularfield loss in 15 of our 24 patients. Two hadtuberculum sella meningiomas (Fig 6), one acraniopharyngioma, and one had an astro-cytoma. Two had optic disc dysversion and onehad optic neuritis (Table 2). CT or MRI showedunilateral extension towards the side of thehemianopia in nine cases, and extension awayfrom the monocular temporal field defect inthree patients. In the others, imaging did notreveal asymmetry of the suprasellar masses. Twopatients had monocular defect without objectiveevidence of visual pathway damage that weattributed to a functional (psychoneurotic) dis-turbance. The functional visual field defectsinvolved both the upper and lower hemifield,whereas the genuine monocular field lossinvolved the upper, or both upper and lowerquadrants.

DiscussionThese patients illustrate an uncommon mani-festation of damage to the visual pathway. Atleast one example of monocular temporal hemi-anopia was recognised in the nineteenth century,andwasprobably on a functional basis. 12 Traquairconcluded that with early chiasmal lesions, theupper temporal defect may only be evident inone field.' According to Scott, 'a lesion at theanterior chiasmal angle extending laterally fromits medial aspect affects first of all the crossedfibres of the affected side with resultant temporalhemianopia on the side of the lesion'.' A genuinejunctional scotoma of Traquair consists of amonocular scotoma with a normal field in thefellow eye.' A junctional scotoma more oftenconsists of a monocular temporal hemianopiawith a central scotoma in the other eye onthe side ofthe lesion. Traquair' also believed thatlesions of the optic tract cause incongruitythat may be extreme, one field showing awell developed quadrantic defect while theother field was normal, but this has notbeen confirmed. He offered the explanation that,'Owing to the fact that at the level of the optictract, the fibres from corresponding retinalpoints had not yet completely come together, asufficiently small lesion in one tract, especially in

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Hershenfeld, Sharpe

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Figure 3 Humphrey visualfield ofpatient with tuberculum sella meningioma, showing monocular temporal defect in eye in thesame patient as illustrated in Figure 1. (A) left eye, (B) right eye.

its anterior portion, may affect one field only andincongruity is common'. '

Complete monocular temporal hemianopia istypically a functional deficit."' 1314 Absence of arelative afferent pupil defect and the persistenceof the hemianopia during binocular field testingeasily distinguishes functional hemianopia fromgenuine hemifield loss. A temporal hemianopiain one eye with a normal field in the fellow eye isincompatible with normal pupillary reactions.Our patients with exclusively monocular defectsand tumours all had an RAPD on the side of fieldloss.

Fifteen out ofthe 24 had a pituitary adenoma asthe cause of the monocular hemianopia, two hadtuberculum sella meningioma, two had optic discdysversion, one case had craniopharyngioma,

one had a low grade glioma (astrocytoma), onehad optic neuritis, and two cases were func-tional. Tilted optic discs may simulate mono-cular or bitemporal hemianopia; the field defectshave sloping margins and do not respect thevertical midline; the temporal defects in all ofourother patients were aligned along the verticalmeridian. Imaging by CT scan or MRI showedunilateral expansion of tumour towards the sideofhemianopia in nine cases, and towards the sideopposite the monocular temporal field defect inthree cases. Precise localisation of tumourimpingement on the chiasm or optic nerve wasnot possible.One patient with optic neuritis presented with

a left monocular temporal scotoma. The OpticNeuritis Study Group detected monoculartemporal hemianopia in 4 5% of 415 patients.'5

Elkington6 reported on the preoperativesymptomatology in 260 patients with pituitaryadenoma. Visual fields, obtained by perimetry,showed unilateral temporal defects in 24 patients(9 2%) of the series. Hoyt3 noted that monoculartemporal scotoma can indicate the presence of aparasellar tumour, but concluded that the peri-metric sign defied logical correlation with estab-lished patterns ofintrinsic chiasmal anatomy. Hestated that monocular hemianopia involving thetemporal field probably represented effects ofocclusion or stasis in nutrient chiasmal vessels.In a series of 1000 cases of pituitary adenoma,7 asuperior temporal defect in one eye was recordedin 33 patients. A paracentral temporal scotomaoccurred in one eye of 12 patients, and a mono-cular inferior temporal defect occurred in four

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Monocular temporal hemianopia

Table 2 Causes ofmonocular hemianopia in 24 patients

Pituitary adenoma 64%Tuberculum sella meningioma 8%Astrocytoma 4%Craniopharyngioma 4%Optic disc dysversion 8%Functional 8%Optic neuritis 4%

Figure S Leftfundus ofpatient whosefield is shown in Figure 4, illustrates dysversion oftheoptic disc.

Figure 6 11 weightedMRl shows tuberculum sellameningiomna in a woman who presented with right monocularsuperotemporal visualfield defect.

patients. In another series8 of 49 patients withtumours compressing the intracranial opticnerve, optic chiasm, or optic tract, most patientshad visual loss predominantly affecting one eye,but authentic monocular temporal hemianopiawas found in only two patients.Monocular temporal hemianopia may be

explained by involvement of the ipsilateral opticnerve close enough to the chiasm to selectivelyimpair conduction in ipsilateral crossing fibresbut too anterior to affect the crossing nasalretinal fibres from the contralateral eye. Nasalcompression or infiltration of the proximal intra-cranial optic nerve ipsilateral to the field defect,where nasal and temporal retinal fibres havebegun to separate, is probably responsible.Retrograde degeneration studies in the monkeychiasm showed that arcuate nerve fibre bundlesremain intact well into the chiasm.4 Nasal andtemporal arcuate bundles may segregate proxi-mal tor that segment of optic nerve where thenasal retinal crossing fibres enter the chiasm.4'6

Tumour compression of the prechiasmal opticnerve segment before the nasal retinal fibresfrom one eye have begun to cross into the chiasmcould explain the monocular hemianopia identi-fied in our patients. Monocular field loss may becaused by a differential mechanical pressureeffect due to asymmetric tumour growth,'7 18 orby differential occlusion of chiasmal nutrientblood vessels.'920Our experience indicates that when temporal

hemianopia is identified in only one eye, juxta-sellar lesions such as pituitary adenoma ormeningioma are likely to be responsible. Theoptic disc may be normal or pale. The presenceof an RAPD with or without optic disc pallor onthe side of the monocular field loss signifiescompression infiltration, or demyelination of theoptic nerve junction with the chiasm.

Presented at the American Academy of Neurology, 43rd annualmeeting, Boston, 24 April 1991 and at the Canadian Ophthalmo-logical Society, 54th annual meeting, Ottawa, 25 June 1991.

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