What is the management approach for a patient with unilateral inferior hemianopsia?

Management of Unilateral Inferior Hemianopsia

For patients with unilateral inferior hemianopsia, visual scanning training is the most evidence-supported rehabilitation approach to improve quality of life and functional outcomes, though evidence remains of low to moderate quality.

Diagnosis and Assessment

• Unilateral inferior hemianopsia is a visual field defect affecting the lower half of vision in both eyes on the same side

• Causes include:

  • Stroke (most common)
  • Brain tumors
  • Traumatic brain injury
  • Multiple sclerosis
  • Neurosurgical procedures

• Essential assessment components:

  • Visual field testing (Goldmann perimetry or automated perimetry)
  • Standardized neurological examination using NIHSS or similar scale
  • Brain imaging (CT/MRI) to identify the causative lesion
  • Mobility assessment to evaluate functional impact

Rehabilitation Approaches

1. Compensatory Training (First-line)

• Visual scanning training is recommended as the primary intervention 1

  • Involves systematic practice of eye movements to compensate for field loss
  • Focuses on developing organized scanning patterns into the blind field
  • Low to moderate quality evidence shows improved quality of life outcomes

• Implementation:

  • Train patients to make larger saccades into the affected field
  • Practice systematic scanning from top to bottom in the affected field
  • Use reading exercises with marked margins to assist with line tracking

2. Substitution Methods (Second-line)

• Optical aids may be considered but have limited evidence:
  • Peripheral prism glasses can expand the visual field
  • Note: Prism adaptation may cause minor but frequent adverse events (headaches) 1

3. Restitution Therapy (Experimental)

• Visual field restitution therapy aims to restore function in the damaged visual field
• Currently insufficient evidence to recommend for or against 1

Special Considerations

Reading Difficulties

• Right hemianopsia: Difficulty seeing ends of words and subsequent text
• Left hemianopsia: Difficulty finding beginning of next line
• Interventions:
  • Mark left margin of text
  • Consider vertical text orientation
  • Practice with laterally scrolling text 1

Mobility and Safety

• Patients with inferior hemianopsia often have:

  • Increased risk of falls (odds ratio 2.86) 1
  • Difficulty with ground-level obstacle detection
  • Problems with step navigation and terrain changes

• Safety recommendations:

  • Environmental modifications to reduce barriers
  • High-contrast marking of steps and level changes
  • Mobility training focused on lower visual field scanning

Monitoring and Follow-up

• Assess adaptation using standardized mobility assessment courses
• Monitor for spontaneous recovery (most likely in first 3 months)
• A cut-off score of ≤25% target omissions on mobility assessment can predict likelihood of adaptation by 12 weeks post-stroke 2
• Special attention to patients with significant inferior visual field loss, as they may require more intensive support 2

Prognosis

• Recovery depends on:

  • Cause and severity of brain injury
  • Time since onset
  • Age and comorbidities
  • Extent of visual field loss (particularly inferior field involvement)
  • Quality and consistency of rehabilitation

• Psychological support is essential as visual field defects can lead to:

  • Decreased independence
  • Social isolation
  • Anxiety and depression
  • Reduced quality of life

Pitfalls and Caveats

• Don't delay treatment of the underlying cause (e.g., thrombolysis for stroke)
• Avoid focusing solely on the visual deficit without addressing psychological impact
• Don't assume spontaneous recovery will occur in all patients
• Rehabilitation should begin early rather than waiting for spontaneous recovery
• Inferior field defects may have worse functional outcomes than superior defects due to their impact on mobility and navigation