What is the management and evaluation approach for an adult patient, possibly older, with a history of neurological or vascular disease, presenting with homonymous hemianopsia, and a past medical history that may include conditions such as hypertension, diabetes, or hyperlipidemia?

Management of Homonymous Hemianopsia

Immediately refer the patient to vision rehabilitation services with occupational therapy as the cornerstone of treatment, focusing on compensatory scanning strategies, assistive technology training, and environmental modifications to restore functional independence in daily activities. 1

Initial Evaluation and Workup

Neuroimaging Requirements

• Obtain MRI brain without and with contrast as the primary imaging modality to identify the underlying etiology (stroke, traumatic brain injury, tumor, or other CNS pathology causing post-chiasmatic damage). 1
• MRI provides superior soft-tissue resolution for evaluating optic nerve pathology and intracranial disease compared to CT. 1
• For acute presentations suggesting stroke, transfer immediately to a stroke-ready facility for time-sensitive evaluation and potential thrombolytic therapy. 2

Stroke Risk Assessment

• Recognize that homonymous hemianopsia carries up to 25% stroke risk, particularly when newly diagnosed, requiring urgent cardiovascular and cerebrovascular evaluation. 1
• Evaluate for embolic sources in patients ≥50 years: carotid ultrasound, echocardiography, and cardiac monitoring for arrhythmias. 1
• Check erythrocyte sedimentation rate and C-reactive protein in elderly patients with temporal tenderness or jaw claudication to rule out giant cell arteritis. 1
• Assess vascular risk factors: blood pressure, hemoglobin A1c, lipid panel, and smoking status. 1, 3

Ophthalmologic Examination

• Document best-corrected visual acuity and check for relative afferent pupillary defect to screen for concurrent optic nerve pathology. 1
• Perform formal visual field testing with Goldmann or Humphrey perimetry to precisely map the defect. 4
• Complete fundoscopic examination to identify papilledema (suggesting elevated intracranial pressure) or optic atrophy. 1
• Assess intraocular pressure and perform gonioscopy if neovascularization is suspected. 1

Vision Rehabilitation Strategy

Occupational Therapy Interventions (Primary Treatment)

Occupational therapy addresses the functional limitations caused by field loss through three core approaches: 1

• Compensatory scanning training: Teach systematic eye movement strategies to scan into the blind hemifield, improving visual search for reading, mobility, shopping, and community activities. 1
• Assistive technology: Train patients to use electronic readers, smartphone/computer modifications, and applications to complete daily tasks despite shortened reading perceptual span. 1
• Environmental and task modifications: Adapt home and workplace settings to maximize remaining vision and reduce collision/navigation hazards. 1

Specific Functional Training Components

• Reading rehabilitation using preferred retinal location strategies and assistive devices to improve accuracy and fluency. 1
• Safe mobility training within the home for activities of daily living (note: outdoor mobility requires separate orientation and mobility specialist, not covered by Medicare). 1
• Driver evaluation and either retraining or transition to driving retirement (not Medicare-reimbursed). 1
• Caregiver education to maximize patient independence while ensuring safety. 1

Additional Rehabilitation Referrals

• State services for the blind and visually impaired for long-term support. 1
• Orientation and mobility services for outdoor navigation training. 1
• Support groups and community aging services for psychosocial adjustment. 1
• Psychology services if depression or adjustment disorder develops. 1

Evidence on Rehabilitation Modalities

Compensatory Eye Movement Training (Most Practical)

• Eye movement-based therapies require the least practice time and show moderate "real-world" improvement with evidence of functional benefit. 5
• This approach has the strongest practical evidence base for improving daily function. 5

Optical Devices (Adjunctive)

• Prisms and optical aids can expand the visual field by bringing the blind area into view, though evidence for standardized methodology is limited. 5, 6
• Consider trial of optical devices as adjunct to compensatory training, not as primary treatment. 5

Visual Restoration Therapy (Controversial)

• Computer-based visual field restitution therapy (NovaVision VRT) has conflicting evidence, with concerns that apparent field expansion may result from small eye movements rather than true restoration. 6
• Functional outcomes show subjective but limited objective evidence of improvement. 6
• Not recommended as first-line treatment given lack of robust evidence and significant time investment required. 6

Prognosis and Follow-up

Spontaneous Recovery Potential

• Approximately one-third of pediatric cases show spontaneous improvement, with 50% improving if evaluated within 1 month of onset. 4
• Adult spontaneous recovery data is less robust, but some improvement possible in first 3-6 months post-injury. 5
• Monitor for 4-6 months before concluding defect is permanent, as neuroplasticity may allow partial recovery. 7

Long-term Monitoring

• Reassess visual fields at 3 and 6 months to document stability or improvement. 4
• Continue occupational therapy throughout recovery period to maximize functional adaptation. 1
• Screen for depression and social isolation, which commonly develop with persistent visual disability. 1

Critical Pitfalls to Avoid

• Do not delay stroke workup in acute presentations: Time-sensitive interventions may prevent further neurological damage. 2
• Do not overlook driving safety: Patients with homonymous hemianopsia have significantly impaired ability to detect hazards and should undergo formal driver evaluation before continuing to drive. 1
• Do not assume patient awareness of deficit: Many patients with hemianopia are unaware of their visual field loss (anosognosia), requiring explicit education about scanning strategies. 1
• Do not focus solely on visual field restoration: Compensatory strategies provide more reliable functional improvement than attempts at field restitution. 5, 6