Quiz: When Words Disappeared

Test your understanding of this case with 10 questions.

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Case Information

Review the case details while answering questions

PATIENT DEMOGRAPHICS

76-year-old male

PRESENTING COMPLAINT

Acute onset difficulty reading. Patient reports 'letters or small words missing' and that 'reading did not make sense'.

EXAMINATION FINDINGS

Visual Acuity: OD: 6/6, OS: 6/6

Pupils: Equal and reactive, no RAPD

Fundus: Normal optic discs and retinal vasculature bilaterally

INVESTIGATIONS

Humphrey 10-2 perimetry showing left homonymous inferior paracentral scotoma in both eyes

Central Visual Field Testing (Humphrey 10-2): Bilateral central 10-degree perimetry revealed the same scotoma in both eyes, consistent with a left homonymous inferior paracentral scotoma. This localizes to a lesion in the right occipital pole above the calcarine fissure.

Neuroimaging (CT/MRI Brain): Stroke in right occipital cortex above the calcarine fissure, corresponding to the visual field defect.

Question 1 of 10

The patient describes "letters or small words missing" and that "reading did not make sense." This description is most typical of which mechanism?

A dominant (left) hemisphere language disorder

Ocular surface disease causing blurred vision

Early dementia affecting reading comprehension

A paracentral scotoma dropping out parts of text

Question 2 of 10

A patient presents with acute reading difficulty, but VA is 6/6 in each eye and the optic discs appear normal. Which of the following best explains this discrepancy?

The patient has early macular degeneration not yet detectable on fundoscopy

Snellen acuity is an unreliable test in elderly patients

A paracentral field defect is affecting reading without reducing Snellen acuity

Reading difficulty in an elderly patient is a normal age-related change requiring no further work-up

Question 3 of 10

Which feature most argues against giant cell arteritis (GCA) as a cause of this presentation?

The patient's visual acuity is completely normal

The patient's age is over 70 years old

The defect is homonymous, not monocular, with no systemic symptoms

The onset of symptoms was acute

Question 4 of 10

The 10-2 perimetry showed the same defect in both eyes. What does this suggest?

A homonymous scotoma

Chronic open-angle glaucoma

Optic neuritis

Bilateral occipital lobe disease

Question 5 of 10

What is the most likely diagnosis?

Acute inflammatory optic neuritis

Acute retinal detachment

Chronic open-angle glaucoma

Right occipital stroke causing a homonymous defect

Question 6 of 10

Why does a lesion above the calcarine fissure cause an inferior, rather than superior, field defect?

The cuneus represents the inferior visual field (retinotopic inversion)

Damage above the fissure paradoxically spares the opposite field

The macula is represented exclusively in the lower bank

The visual pathway crosses an extra time in the occipital lobe

Question 7 of 10

This patient initially presented to a GP who checked VA, found it normal, and reassured the patient. What was the critical error, and what should have been done instead?

The VA chart should have been at 3, not 6, metres

Formal visual field testing was never performed at all

Colour vision testing was omitted from the exam

VA should have been tested using a pinhole

Question 8 of 10

If neuroimaging confirms an acute occipital infarct, what is the expected pattern of visual recovery?

Some deficit often persists, with only partial improvement over weeks

The defect will convert to complete bilateral blindness

Complete resolution is expected within 24 hours

Vision will progressively worsen regardless of any treatment

Question 9 of 10

What is the most appropriate immediate next step in management?

Refer urgently for neurological stroke work-up

Reassure the patient fully and discharge home

Refer urgently to ophthalmology for further assessment

Start high-dose steroids for optic neuritis

Question 10 of 10

How does this presentation differ from classic "alexia without agraphia" (pure word blindness), despite both sometimes being described as "reading difficulty" from occipital pathology?

Alexia without agraphia is a language disorder; this is a visual field defect

They are the same underlying condition, just described differently

Alexia without agraphia occurs only in right-handed patients

This is simply a more severe version of alexia