The natural history of homonymous hemianopia revisited

ObjectiveTo re-evaluate the longitudinal progression of stroke-induced homonymous visual field defects using strictly automated perimetry (Zeiss Humphrey Systems), rigorous inclusion/exclusion criteria, and quantitative analyses. MethodsA retrospective chart review of stroke patients diagnosed with "homonymous hemianopia", who underwent monocular Humphrey visual field (HVF) perimetry using the 24-2 SITA standard pattern from 2011-2019, was conducted at a large US academic medical center. Reliable tests (<20% fixation losses, false positives, and false negatives) were identified and analyzed with generalized estimating equations to extract temporal trends in perimetric mean deviation (PMD) and deficit area. ResultsOf 532 patients with "homonymous hemianopia", sequential, reliable HVFs were only available for 36 patients in the right eye, and 30 patients in the left eye, ranging from 7 days to 58 months post-stroke. Both PMD and deficit area improved early, within the first 3 months post-stroke; however, this was followed by a subsequent decline in performance >1 year post-stroke. Changes were similar between eyes. ConclusionWe discovered that a large portion of occipital stroke patients do not receive comprehensive ophthalmologic follow-up and, even then, only a fraction of HVFs performed are reliable enough for rigorous analysis. Nonetheless, reliable HVFs in such patients confirmed early visual improvement after stroke, consistent with prior reports. However, in contrast with prior, qualitative reports, there was no stability of the deficit beyond 6 months post-stroke; instead, gradual worsening erased the initial spontaneous improvement, especially >1 year post-stroke.