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Clinical Conundrums: Case History 2 - ‘Pie on the Floor’
From Caroline King & Priscilla Darkwah:
We today examined a 34 year old female patient who attended for a routine 2-yearly eye examination. She was reporting a slight deterioration in her distance visual acuity, which was more noticeable when driving. There were no problems at near. She was otherwise asymptomatic, no headaches, diplopia or any other complaints.
Her general health was good and she was not taking any medication. However the patient recalled an episode 5 months ago of persistent severe headache with nausea, vertigo, pins and needles down her left arm and leg and also some visual disturbances which she could only vaguely recall and was unable to elaborate. This episode had lasted continuously for 2 weeks; she had found it very debilitating and had taken absence from work. After a visit to the GP, she was given a diagnosis of migraine; no further action, investigation or treatment was taken.
She had no previous ocular history and there was no family ocular or medical history.
Refractive Status
R -3.75 / -0.75 x 20 6/6 +2 reading N5
L -4.25 / -1.00 x 170 6/6 +1 reading N5
Oculomotor balance: orthophoric.
Accommodation and convergence: normal.
Motility: full and smooth in all positions of gaze.
Ocular examination
Pupils normal to direct, consensual and near and there was no relevant afferent pupil defect.
The optic nerve heads were symmetrical in appearance, CD 0.2, flat distinct margins, NRR healthy; the retina was unremarkable with no abnormalities detected. Both maculae were flat, clear reflex seen (Binocular indirect examination).
Pie on the Floor LEFT full size
Pie on the Floor RIGHT full size
Routine visual field testing with the Humphrey Field Analyzer, Central 30-2 Threshold test gave the following visual field defect: the defect was repeatable. The defect was an inferior quadrantanopia.
On today’s finding we referred the patient via her GP for a prompt neurological investigation.
Given the findings, and the visual field defect, we considered a possible diagnosis of ‘pie in the floor,’ and now await the outcome from the hospital. As this is not something we have come across before, we wondered if anyone else has had a similar finding or perhaps a comment to make?
Peter Chapman // Mar 23, 2007 at 2:37 pm
This visual defect is not one I have seen in practice, and I believe is very rare, but arises from a neurological defect at the optic radiations of the Left parietal lobe.
The anatomy of the visual pathway is such that the superior firbres of the optic radiations pass through the parietal lobe and on to the occipital cortex.
This area of the brain is responsible for integrating sensory information from different parts of the body, as well as movement, orientation, recognition and perception of stimuli.
The field defects are denser inferiorly but can invade the superior quadrants if the cause is bordering on the temporal lobe.
The cause of the defect needs to be identified, but posibilities include a stroke or space occuping lesion.
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