Nursing Assignment

Crossed Quadrant Homonymous Hemianopsia (CQHH)

Synonym

• Checkerboard visual field deficit

ICD 10

Definition

Rare homonymous loss of two opposite quadrants of the visual field which may lead to sudden or gradual loss of vision. Groenouw documented the first case in 1891.

Epidemiology

This rare condition only had nine reported cases in medical literature from 1891-1982. Currently, newer cases have been reported which are associated with bites from vipers and Multiple sclerosis, and with different presentations.

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Risk factor include:

• Trauma
• High blood pressure or hypertension
• Coronary artery disease
• Atherosclerosis
• Tertiary syphilis
• Previous stroke

• Multiple Sclerosis
• cerebral infarcts principally from the calcarine arteries’ embolization on or after vertebral or basilar branches

Pathophysiology/Etiology

The defects in CQHH extend across the horizontal media, although they often spare the vertical median. These cases arise from either two separate or two simultaneous events. Visual fields may be affected in succession or simultaneously with the latter being the most popular.

CGHH results from the vertebra-basilar ischemia and associated with the calcarine fissure’s bilateral injury. It is characterized by the striate cortex’s bilateral lesions. These lesions are often cerebral infarctions located in one hemisphere’s lower calcarine bank and to the contralateral one’s upper bank.

Studies also show that CQHH may be caused by damaged optic radiations.

Clinical History

Groenouw noted that his patient had a stroke, a left homonymous hemianopsia and a left hemiplegia. Eye symptoms were first reported in 1926 in the British Journal of Ophthalmology.

Visual field defects characteristics include:

• Small zones of visual field loss are demonstrated by the unbroken quadrants
• Preservation of central vision
• The ostensible incongruity of field testing may indicate the presence of Riddoch phenomenon
• The defects often extend across the horizontal midline but with the vertical midline spared
• The monocular temporal crescent may be spared
• The patient may experience simple or complex visual hallucinations in the seeing or blind field
• Abnormal color vision
• Defects arising from two concurrent quandrantanopsias. There may be two consecutive homonymous hemianopsia where each resolves into a quadrantanopsia. Besides, a concurrent bilateral homonymous hemianopsia resolves into crossed quadrant defects

Differential DX

Differential diagnosis of CQHH include:

• Trauma
• Stroke
• Migraine

• Demyelinating Process
• Tumor
• Inflammatory Process

Examination

Diagnostic procedures aim to establish whether the calcarine arteries’ embolization emanates from vertebral or basilar branches. The embolization can also result from thromboembolism due to cardiac disease. Ischemia, hemorrhagic stroke, viper bites, vessel dissection, and cervical-vertebral trauma are associated with CQHH and should be investigated through:

• CT scan

• Goldmann Visual Field
• Magnetic resonance imaging
• Humphrey’s computer field analysis or Humphrey field analyzer

Further ophthalmic evaluation can also be performed. It may include visual acuity tests, pupil reaction tests, optokinetic nystagmus testing, fundus examination, and cornea sensation testing.

Neurological examinations may be necessary in some cases such as patients with multiple sclerosis. Findings may include dissociated nystagmus with internuclear ophthalmoplegia, limbs with cerebellar ataxia experiencing motor coordination difficulties, a wide-based gait, and bilateral extensor plantar responses. Others may include increased tone throughout and the lower limbs severely losing strength while the upper ones exhibit mild weakness.

Workup

See examination

Treatment

Management of CQHH includes:

• Low vision aids and care with visual rehabilitation
• Anti-platelet therapy. This treatment is started in consultation with a neurologist because sometimes the cause may arise form posterior cerebral ischemia or vertebrobasilar disease due to original cervical spine injury
• Checkerboard prisms to expand the intact visual field. The patient will see images that usually fall on the hemianopic retina shift to become visible by the seeing retinal segment. However, literature reports varying success levels with this method.

Follow Up

The follow-up schedule is provided by the ophthalmologist according to patient response to treatment.

Research

There are currently no studies underway on Clinical Trials.gov.

https://clinicaltrials.gov/ct2/results?cond=Crossed+Quadrant+Homonymous+Hemianopsia+%28CQHH%29&term=&cntry=&state=&city=&dist=

References

Dyer, J. A., Hirst, L, W., Vandeleur, K., Carey, T., & Mann, P. R. (1990). Crossed-quadrant homonymous hemianopsia. J Clin Neuroophthalmol. 10(3), 219-22. PMID: 2144542.

Links

https://eyewiki.aao.org/Crossed_Quadrant_Homonymous_Hemianopsia

Date: 20201009