OE
OphthalmoEducate
Back to Case

Quiz: The Quiet Quadrant

Test your understanding of this case with 12 questions.

Progress0 / 12 completed
Case Information
Review the case details while answering questions

PATIENT DEMOGRAPHICS

64-year-old female

PRESENTING COMPLAINT

Attends for routine visual field assessment as part of ongoing monitoring for chronic (primary open-angle) glaucoma. No new visual symptoms volunteered. Specifically denies any awareness of visual field loss and reports never bumping into objects or furniture.

EXAMINATION FINDINGS

Visual Acuity: OD: Hand Movements (HM) — longstanding amblyopia, unchanged from baseline. OS: 6/6

Pupils: Equal and reactive, no RAPD

Fundus: OD — optic disc unremarkable; longstanding amblyopic eye, no acute pathology. OS — optic disc shows an asymmetric cup with superior neuroretinal rim notching.

INVESTIGATIONS

Right fundus photograph — optic disc appearance unremarkable in the longstanding amblyopic eye

Right fundus photograph — optic disc appearance unremarkable in the longstanding amblyopic eye

Left fundus photograph — asymmetric cupping with superior neuroretinal rim notching consistent with glaucomatous optic neuropathy

Left fundus photograph — asymmetric cupping with superior neuroretinal rim notching consistent with glaucomatous optic neuropathy

Fundus Photography: Right fundus: optic disc appearance unremarkable; longstanding amblyopic eye with no additional posterior segment pathology. Left fundus: optic disc demonstrates asymmetric cupping with superior neuroretinal rim notching, consistent with glaucomatous optic neuropathy.

OCT Optic Disc Analysis: Average RNFL Thickness: OD 85μm, OS 78μm. RNFL Symmetry: 61%. Rim Area: OD 1.42mm², OS 1.11mm². Disc Area: OD 1.84mm², OS 1.59mm². Average C/D Ratio: OD 0.47, OS 0.54. Vertical C/D Ratio: OD 0.49, OS 0.57. Cup Volume: OD 0.026mm³, OS 0.081mm³. Asymmetric findings with more advanced cupping, thinner RNFL, and greater cup volume in the left eye, correlating with the superior rim notching seen clinically.

Automated perimetry printout showing a right superior homonymous quadrantanopia with a superimposed inferior arcuate scotoma

Automated perimetry printout showing a right superior homonymous quadrantanopia with a superimposed inferior arcuate scotoma

Visual Field Testing: Demonstrates a right superior homonymous quadrantanopia, together with an additional right-sided inferior arcuate scotoma pattern superimposed on the homonymous defect — two distinct field defect patterns coexisting in the same eye.

Axial MRI brain demonstrating established infarction of the left inferior occipital cortex (lingual gyrus)

Axial MRI brain demonstrating established infarction of the left inferior occipital cortex (lingual gyrus)

Neuroimaging (MRI Brain): Demonstrates an area of established infarction involving the left inferior occipital cortex (lingual gyrus) — the region representing the superior visual field due to the inverted retinotopic organisation of the primary visual cortex, explaining the right superior homonymous quadrantanopia.

Question 1 of 12

This patient's right eye has always measured Hand Movements vision due to longstanding amblyopia. What is the clinical significance of this finding in the context of her current presentation?

Question 2 of 12

The MRI shows an infarct in the left inferior occipital cortex. Why does this produce a defect in the superior, rather than inferior, visual field?

Question 3 of 12

Which feature of the right inferior arcuate scotoma helps distinguish it from the homonymous quadrantanopia found in the same patient?

Question 4 of 12

The left optic disc shows superior neuroretinal rim notching. What field defect would this be expected to produce?

Question 5 of 12

The OCT shows an average RNFL thickness of 78μm in the left eye versus 85μm in the right, with an RNFL symmetry of 61%. What does this pattern suggest?

Question 6 of 12

What is the most likely diagnosis?

Question 7 of 12

Despite her reported lack of awareness of any visual field loss, why is this case clinically concerning?

Question 8 of 12

Which element of this patient's history most directly increased her risk of the occipital infarct?

Question 9 of 12

Visual field testing showed both a homonymous-pattern defect and an arcuate-pattern defect in the same eye. Why did this combination specifically warrant neuroimaging, rather than attributing all findings to her known glaucoma?

Question 10 of 12

Which specific finding on this patient's visual field belongs to the glaucomatous process, rather than the occipital infarct?

Question 11 of 12

What is the most appropriate next management step for this patient?

Question 12 of 12

Given the combination of field defects now confirmed, what practical safety issue should specifically be assessed and discussed with this patient?