🔹 About 30% of stroke patients develop post-stroke visual impairment. 🔹 Common symptoms: hemianopia, neglect, diplopia, ↓ visual acuity, ptosis, anisocoria, nystagmus. 🔹 Homonymous hemianopia affects ~8% of stroke patients – some may still be driving.

🧬 Aetiology

👁️ Homonymous hemianopia: Loss of the same right/left halves of the visual field in both eyes. ➡️ Cause: Stroke of optic radiation or occipital cortex (MCA or PCA infarcts). ➡️ Macular sparing may occur if dual MCA/PCA supply to occipital pole.
◼️ Quadrantanopia:
- 🌙 Superior quadrantanopia: Temporal lobe lesion (“pie in the sky”).
- 🌄 Inferior quadrantanopia: Parietal lobe lesion (“pie on the floor”).

📊 Range of Visual Field Losses

Visual Loss	Cause & Summary
Altitudinal defect	BRAO, optic neuropathy, retinal detachment, glaucoma
Central scotoma	Macular disease, optic neuritis/atrophy
Monocular blindness	CRAO, GCA, PMR, or vascular risk factors
Monocular quadrantanopia	Branch retinal artery occlusion
Dynamic loss (scotoma, aura)	Migraine with aura
Bitemporal hemianopia	Pituitary tumour, craniopharyngioma → MRI required
Lower homonymous quadrantanopia	Contralateral temporal lobe stroke
Upper homonymous quadrantanopia	Contralateral parietal lobe stroke
Complete homonymous hemianopia + motor/sensory deficit	Large MCA infarct
Complete homonymous hemianopia (no motor deficit)	PCA occipital infarct
Complete blindness	Rare, unless multiple bilateral lesions
Prosopagnosia	Inability to recognize faces (bilateral inferior occipital/temporal lesions)

👁️ Left Homonymous Hemianopia (Patient’s View)

🔍 Visual Neglect

🧭 A parietal lobe syndrome → patients ignore one side (usually left). 🪒 May shave/eat only one side. 💡 Managed with occupational therapy & compensatory scanning strategies.

📖 Hemianopic Alexia

📚 Reading disorder post-stroke, usually left hemisphere → disrupts right visual field used for guiding eye movements. 🚨 Common, distressing, requires rehab input.

🚗 Driving & Visual Field Defects

Complete hemianopia = unsafe to drive. DVLA guidelines require assessment before resuming driving. DVLA guidance.

📏 DVLA Minimum Standards for Group 1 Drivers

120° horizontal field (≥50° left & right).
No binocular defect within 20° of fixation.
Homonymous/bitemporal defects close to fixation = not permitted.

DVLA testing includes: ✔️ Binocular Esterman field test (standard) ✔️ Monocular full-field charts (specific cases) ✔️ Goldmann perimetry (rare, strict criteria)

💊 Management of Visual Field Defects

Multidisciplinary rehab: ophthalmology, orthoptics, OT, stroke physicians.
Education + compensatory scanning strategies.
Prism lenses → shift visual field.
Refer to patient resources (Chest Heart & Stroke Scotland sheet).
Prognosis variable → reassess at 2–3 months.

📚 References

[1] Gilhotra JS, Mitchell P, Healey PR, et al. Homonymous visual field defects and stroke. Stroke 2002;33:2417-20.
[2] Visual field defects after stroke. Aust Fam Physician, 2010.
[3] DVLA Standards for Fitness to Drive.

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Stroke and Vision

🧠 Introduction