Binocular Visual Field and Vision-Related Quality of Life in Patients With Hemianopia

Hemianopias can have a severe impact on functional ability and quality of life (QoL). Binocular visual field (VF) analysis is clinically more relevant to visual function than monocular VF. The aim is to analyze the binocular VF of patients with hemianopias and its association with the monocular VF and to assess the QoL of these patients through questionnaires specifically related to vision compared with healthy controls

Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD Binocular Visual Field and Vision-Related Quality of Life in Patients With Hemianopia Barbara Burgos-Blasco, MD, Pilar Perez-Garcia, MD, Jose I. Fernandez-Vigo, MD, PhD, Blanca Benito-Pascual, MD, Elena Hernandez-Garcia, MD, PhD, Federico SaenzFrances, MD, PhD, Enrique Santos-Bueso, MD, PhD Background: Hemianopias can have a severe impact on functional ability and quality of life (QoL). Binocular visual field (VF) analysis is clinically more relevant to visual function than monocular VF. The aim is to analyze the binocular VF of patients with hemianopias and its association with the monocular VF and to assess the QoL of these patients through questionnaires specifically related to vision compared with healthy controls. Methods: The case–control study included patients with hemianopias and controls. Sex, age, general history, etiology, location of the lesion, and time since the lesion appeared were recorded. Monocular VF and Esterman binocular VF were performed. VF defect, mean defect (MD), and Esterman scores were recorded. Visual Activities Questionnaire (VAQ-33) and Visual Function Questionnaire (VFQ-25) questionnaires were administered. Results: Twenty patients with hemianopia and 22 healthy controls were included. The Esterman score in homonymous hemianopia patients (n = 17) correlated with best eye MD (r = 20.62, P = 0.01), worst eye MD (r = 20.70, P = 0.002), and average MD (r = 20.68, P = 0.003). Compared with healthy control subjects, patients with homonymous hemianopia had significantly lower VFQ-25 score and in 10/12 subscales (all P , 0.001). VAQ-33 scores revealed lower overall and subscales scores with the exception of light/dark adaptation (P = 0.08). Correlations were found between monocular and binocular VF scores and general vision (r = 20.55), peripheral vision (on both questionnaires, r-range 20.75 to 0.47), VFQ-25 and VAQ-33 overall scores (r = 20.59, 20.49 and 0.50), and glare disability (r = 0.53 and 0.67). Ophthalmology Department (BB-B, PP-G, JIF-V, BB-P, EH-G), Hospital Clínico San Carlos, Madrid, Spain; and Ophthalmology Department (FS-F, ES-B), Instituto de Investigación sanitaria del Hospital Clínico San Carlos (IdISSC), IIORC, Universidad Complutense, Madrid, Spain. The authors report no conflicts of interest. Address correspondence to Barbara Burgos-Blasco, MD, Ophthalmology Department, Hospital Clinico San Carlos, Calle Profesor Martin Lagos s/n, Madrid 28040, Spain; E-mail: [e-mail] Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 Conclusions: Hemianopic VF defects involve a major alteration in the patients’ vision-related QoL. Journal of Neuro-Ophthalmology 2022;42:e217–e224 doi: 10.1097/WNO.0000000000001286 © 2021 by North American Neuro-Ophthalmology Society H emianopia results in loss of one-half of the visual field (VF) in both eyes and is the main visual morbidity of chiasmatic and retrochiasmatic disorders, frequently precluding common daily activities (1). The etiology of these defects varies according to age, comorbidities, and the location of the lesion along the visual pathway. In chiasmatic syndromes, the classic VF defect is a bitemporal hemianopia secondary to a tumor in most cases. Homonymous hemianopia or quadrantanopia result from retrochiasmatic disorders such as ischemic events, hemorrhages, and tumors, its most common location being the occipital lobe (2,3). When analyzing the VF, usually each monocular VF is tested, but binocular VF analysis is clinically more relevant, reflecting real binocular visual function. However, most perimeters are not designed for binocular testing. Therefore, methods of predicting binocular VF sensitivity from monocular tests have been analyzed. These predictions are based on the VF of the eye with more sensitivity, the average sensitivity, the highest sensitivity between eyes, and binocular summation (4). They have been investigated in patients with glaucoma, most models indicating a good correlation of the binocular VF with the best eye (5,6). However, there are no studies in hemianopia and quadrantanopia. Investigating binocular VF in large defects such as hemianopia is of enormous relevance given that many daily activities such as driving, reading, and mobility skills are more dependent on the status of the binocular rather than the monocular VF (7). Hence, hemianopias can have a severe impact on quality of life (QoL) as well as profound psychological, employment, and financial consequences (8–11). e217 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution It is important to objectively analyze QoL in these patients, and self-reported outcome questionnaires have been developed. Many of these questionnaires, such as Visual Activities Questionnaire (VAQ-33) and National Eye Institute Visual Function Questionnaire (VFQ-25), include questions related to common activities of daily living. Studies with these questionnaires, in glaucoma mainly, have reported that VF loss associates with reduced vision-related function (5,12,13). However, QoL in patients with hemianopic and quadrantanopic defects and binocular VF approximations have not been thoroughly investigated. This study was designed to analyze the binocular VF of patients with hemianopias and quadrantanopias and its association with monocular VF and assess their visionrelated QoL. Such knowledge will be compared with healthy individuals to investigate in which subscales the QoL is particularly affected. METHODS Setting and Subjects This case–control study was performed at Hospital Clinico San Carlos in Madrid, which included patients with hemianopias or quadrantanopias and controls. Patients older than 18 years with the best-corrected visual acuity (BCVA) of 20/40 or better in each eye at distance and a stable VF defect in 2 consecutive VF compatible with hemianopia or quadrantanopia were consecutively recruited as case group. As exclusion criteria; the presence of a concomitant ophthalmological disease (including optic nerve pathology anterior to the chiasm, retinal pathology, vascular pathology, and important alterations of the ocular surface), spherical equivalent refractive errors greater than 5 diopters, inability to perform the VF test or answer the questionnaire, poor general condition, lack of collaboration or visual inattention, cognitive impairment, and refusal to participate were considered. Sex, age, general history, etiology, location of the lesion, and time since the lesion appeared were recorded. For the control group, healthy patients older than 18 years with the BCVA of 20/40 or better in each eye at a distance with no ophthalmological diseases came for routine ophthalmological examination were included. The same exclusion criteria were considered. 24-2 and Esterman software for the binocular VF. Esterman perimetry is a binocular test method of 120 white test points displayed with a higher threshold, without adjustable light intensity, of 10 dB (decibeLs) and scans 160° horizontally and vertically from 30° superiorly to 60° inferiorly (Fig. 1). It allows the visual defects of both eyes to be compensated and assesses the actual binocular VF. The Esterman test scores are based on a relative value scale, which is divided into unequal units of 120. Each unit is equated to one test point and is given a value of 0.83% in the binocular field. The inequality in the size and distribution of the units, with greater unit density in more important areas, makes the scale functional. From the monocular VF, the type of VF defect and the mean defect (MD) in dB were recorded. Patients whose VF was considered unreliable (.33% false positives or false negatives, or .20% fixation losses) were not included in the study. From the binocular VF, the percentage of the 120 VF test points that were correctly detected during the test was recorded. Questionnaire Administration Regarding QoL, the results of VAQ-33 and VFQ-25, which assess patients’ perceptions of their functioning vision and the impact of visual problems on their daily activities, were recorded. The questionnaires were administered by an interviewer who was independent of the treating neuroophthalmologist. Because patients with homonymous field loss are clinically very different in their visual disability compared with those with bitemporal visual field loss, only patients with homonymous defects were included in the QoL analysis. The VFQ-25 returns 12 subscale scores: general health, general vision, near vision, distance vision, driving, Ophthalmological Examination In all subjects included in the study, an ophthalmological examination was performed, including BCVA, intraocular pressure, biomicroscopy, and funduscopy. The BCVA was measured according to the Early Treatment Diabetic Retinopathy Study (ETDRS), and both eyes were averaged. In addition, in the hemianopia patients, automated static perimetry was performed using a Automated field analyzer (Carl Zeiss Meditec Inc, Dublin, CA) with SITA-Standard e218 FIG. 1. Esterman visual field example showing how the right and left eye visual fields overlap. Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution peripheral vision, color vision, and ocular pain, as well as limitations of specific vision functions, dependence, social function, and mental health. An overall score is generated by averaging the 11 vision-related subscales without general health. Subscale and overall scores range from 0 to 100, with higher scores indicating better visual functioning (14). The VAQ-33 obtains the person’s report on their ability to perform daily tasks and activities that involve vision. Each item describes a possible vision problem and asks how often this problem occurs on a 5-point scale from 1 (never) to 5 (always). The VAQ-33 includes 8 subscales: color discrimination, glare disability, light–dark adaptation, acuity/spatial vision, depth perception, peripheral vision, visual search, and visual processing speed. The total VAQ score and the subscale scores were calculated as the mean of all items, or items on that subscale, respectively. Scores range from 1 to 5, with higher scores indicating poorer visual functioning (15). means and standard deviations (SD) or as frequencies and percentages. The overall scores and subscale domains of the VFQ-25 and VAQ-33 are expressed as a mean and SD. SD scores (SDS) were calculated as the average VFQ-25 and VAQ-33 subscale scores in the case group minus the corresponding average values of the healthy controls divided by the SD of the control sample (16). Associations between binocular approaches and binocular VF data were assessed using Pearson’s correlations in homonymous hemianopia patients and Spearman’s rank correlation in bitemporal VF loss patients. Correlations were compared using the Zou method. Univariate analysis of QoL questionnaires were compared between the hemianopia patients and the controls using a 2-tailed Student t test. P , 0.05 was considered statistically significant. Statistics RESULTS Statistical analyses were performed with SPSS software, version 25.0 (IBM, New Castle, NY). The characteristics of the patients and measurements of the VF are presented as The final study population comprised 42 individuals: 20 patients with hemianopia and 22 healthy controls. Of the initial 43 patients with hemianopia selected, 23 were TABLE 1. Clinical and ophthalmological characteristics of the patients with hemianopia Hemianopia Patients (n = 20) Age (yr) Sex Male Female Etiology of lesion Ischemic event Tumor Hemorrhagic event Trauma Location of lesion Occipital lobe Optic radiations Optic tract Optic chiasm Lateral geniculate body Multiple Mean BCVA (ETDRS) Visual field defect Homonymous hemianopia Quadrantanopia Bitemporal hemianopia Side of visual field defect Right visual field Left visual field Bitemporal defect Visual field scores MD best eye (dB) MD worst eye (dB) MD difference between eyes (dB) Average MD (dB) Esterman score (%) 62.3 ± 15.4 15 (75%) 5 (25%) 10 (50%) 5 (25%) 3 (15%) 2 (10%) 7 (35%) 6 (30%) 1 (5%) 3 (15%) 0 (0%) 3 (15%) 73.2 ± 6.5 11 (55%) 6 (30%) 3 (15%) 12 (60%) 5 (25%) 3 (15%) 15.8 ± 5.9 12.0 ± 4.4 4.5 ± 3.2 13.9 ± 4.9 64.3 ± 14.1 BCVA, best-corrected visual acuity; ETDRS, Early Treatment Diabetic Retinopathy Study; MD, mean defect. Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 e219 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution excluded because of poor general health condition, inability to perform VF and visual inattention (15), unreliable VF tests (4), concomitant ophthalmological disease (3), and inability to answer the questionnaire (1). Table 1 illustrates the main characteristics of the case group. The mean follow-up of the patients was 3.9 ± 2.6 years (range 7 months–9 years). As for the control group, the mean age was 55.9 ± 13.4 years (range 32–82), with 16 men (73%) and 6 women (27%). The mean BCVA was 81.2 ± 5.3 ETDRS letters. The reasons for referral in the control group were general eye assessment. No differences in age and sex were found between groups (P . 0.05). The Esterman score in homonymous hemianopia patients correlated with best eye MD (r = 20.62, P = 0.01), worst eye MD (r = 20.70, P = 0.002), and average MD (r = 20.68, P = 0.003) (Fig. 2). No statistically significant differences were found between best eye and worst eye correlations with the Esterman score in these patients (P = 0.293, CI 95% 20.12 to 0.37). In patients with bitemporal VF loss, correlation of the Esterman score with best eye MD (r = 0.50), worst eye MD (r = 20.50), and average MD (r = 20.50) were not statistically significant (all, P . 0.05). Compared with healthy control subjects, patients with homonymous hemianopia (n = 17) had significantly lower vision-related QoL in the VFQ-25 composite score and in 10 of the 12 subscales (all P , 0.001) (Table 2). Driving (10.1 ± 22.0) and peripheral vision (29.4 ± 37.7) received the lowest subscale scores. Only the subscales ocular pain and color vision did not differ to healthy controls (P . 0.05). The comparison of VAQ-33 scores for both groups revealed a significantly lower overall score and in all subscales with the exception of light/dark adaptation (P = 0.08). Peripheral vision (3.6 ± 1.4) and acuity/spatial vision (3.3 ± 1.4) received the worst subscale scores. The relationship in the subscales in patients with hemianopia relative to healthy controls is illustrated in Figure 3 using SDS. In the VFQ-25 subscales negative values show worse functioning, whereas in the VAQ-33 worst functioning is represented by positive values. VFQ and VAQ-33 subscales were correlated with the different monocular and binocular VF scores. Statistically significant correlations were found with general vision (r = 20.55), peripheral vision (on both questionnaires, r-range 20.75 to 0.47), overall scores (r = 20.59, 20.49 and 0.50), and glare disability (r = 0.53 and 0.67, Table 3). However, when correction for multiple comparisons is applied, only correlation with peripheral vision in both questionnaires remains statistically significant. DISCUSSION Hemianopic and quadrantanopic VF loss can have a significant effect on QoL, including problems with driving, reading, or navigation. We analyzed the binocular VF of e220 patients with hemianopias and its association with the monocular VF, finding a better correlation with the worst eye MD. Our results show that patients’ QoL is affected in all subscales of VFQ-25 and VAQ-33, particularly driving and peripheral vision. Binocular VF are more closely related to how the patient functions in daily life compared with monocular VF. Given that most VF analyzed in clinical practice are monocular, several studies have analyzed whether a good approximation of the real binocular VF can be made through them. In glaucoma, the most studied pathology in this regard, Xu et al (17) reported that in patients with one unaffected or early glaucoma eye and the other severely affected, the mean FIG. 2. Scatter plot showing the linear regression between the Esterman score and binocular approximations in homonymous hemianopia patients: (A) best eye mean defect (r = 20.62, P = 0.01), (B) worst eye mean defect (r = 20.70, P = 0.002), and (C) average mean defect (r = 20.68, P = 0.003). Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 2. VFQ-25 and VAQ-33 results of patients with homonymous hemianopia compared with healthy controls Questionnaire VFQ-25 subscales General health General vision Ocular pain Near activities Distance activities Social functioning Mental health Role difficulties Dependency Driving Color vision Peripheral vision Overall score VAQ-33 subscales Color discrimination Glare disability Light/dark adaptation Acuity/spatial vision Depth perception Peripheral vision Visual search Visual processing speed Overall score Homonymous Hemianopia Patients (n = 17) 64.7 67.1 90.4 55.9 75.5 72.1 73.5 67.7 77.0 10.1 85.3 29.4 64.3 ± ± ± ± ± ± ± ± ± ± ± ± ± 1.9 3.1 2.3 3.3 2.1 3.6 2.7 2.6 2.7 17.8 15.7 12.9 31.0 22.9 26.3 26.7 25.4 32.3 22.0 19.9 37.7 17.0 ± ± ± ± ± ± ± ± ± 1.4 1.0 1.2 1.4 1.3 1.4 1.1 1.1 1.0 Control Group (n = 22) P 80.7 ± 15.3 84.6 ± 13.1 88.1 ± 13.1 86.0 ± 19.7 92.8 ± 11.3 97.2 ± 6.6 90.9 ± 10.2 94.3 ± 9.2 98.9 ± 5.3 89.0 ± 15.2 94.3 ± 15.3 96.6 ± 8.8 92.0 ± 7.7 ,0.01 ,0.01 0.47 ,0.01 ,0.01 ,0.01 ,0.01 ,0.01 ,0.01 ,0.01 0.12 ,0.01 ,0.01 1.7 1.6 1.8 2.0 1.2 1.2 1.4 1.4 1.5 ± ± ± ± ± ± ± ± ± 0.4 0.6 0.7 1.0 0.4 0.4 0.6 0.6 0.4 0.01 ,0.01 0.08 ,0.01 ,0.01 ,0.01 ,0.01 ,0.01 ,0.01 VAQ-33, Visual Activities Questionnaire; VFQ-25, Visual Function Questionnaire. Esterman scores were .95%. When both eyes presented moderate damage, the Esterman mean scores were still .90%, but fell to 68% when both eyes went into a severe stage. Also in glaucoma patients, Musch et al (6) found a statistically significant correlation of the Esterman score with all binocular VF approaches, with r values from 0.31 (MD of the worst eye) to 0.42 (MD of the best eye; all P ,0.001). Hence, most studies agree that the binocular VF in glaucoma patients resembles the best monocular VF more than that of the most affected eye. This contrasts with our results, in which the Esterman score seems to correlate better with the eye with the worst VF MD, although no statistical differences could be found. These results may be due to the fact that the patients included in those studies had lower MD and therefore less VF involvement, which is reflected in a better Esterman score. In large VF defects such as hemianopias, the binocular VF might correlate better with the MD of the worst eye. However, there are no reports in the literature about hemianopic and quadrantanopic VF in this regard. QoL has been analyzed in different ophthalmologic diseases with VF loss such as glaucoma, retinal disorders, and optic neuropathy (18–21). In stroke patients with hemianopia, Gall et al (16) evaluated QoL with VFQ-25, describing lower scores in all subscales but ocular pain compared with healthy controls. However, Gall et al describe a Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 partial correlation between VFQ-25 subscales and BCVA (r-range 0.27–0.48), which we believe may be not due to the VF defect, given that hemianopic patients present good visual acuities in the absence of ophthalmological disorders, such as cataract. Similar findings have been described by Wagenbreth et al (22) and Chen et al (23) which agree with our results in the overall score and most subscales, illustrating the substantial impact of vision impairment on the vision-related QoL perceived by patients with hemianopia. In the VFQ -25 questionnaire, our patients scored lowest in driving and peripheral vision, which is consistent with the most affected subscales reported in the literature (8,22,24,25). There is increasing research on whether the binocular VF correlates with daily activities such as driving, reading, looking for specific items, and falls. In glaucoma, the link between Esterman binocular VF and QoL has been analyzed with good results (26). Lombardi’s group (27) evaluated the correlations between VF and the performance of glaucoma patients in simulated daily activities, obtaining better correlations with the MD of the best eye and the Esterman. Also in glaucoma, Kulkarni et al (28) depicted how VFQ-25 scores were associated most closely with the visual score in the best eye and the binocular VF. Spearman correlations showed scores in the best eye having a closer relationship with VFQ-25 scores. Wren et al reported that best eye VF and worse eye (regarding visual acuity) had the e221 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution FIG. 3. Standard deviation scores for VFQ-25 (A) and VAQ-33 (B) of homonymous hemianopia patients compared with a healthy reference group. SDS were calculated as the average subscale scores in the case group minus the average value of healthy control subjects divided by the standard deviation of the control sample. The zero-line represents the baseline value of the healthy individuals. SDS, SD scores; VAQ-33, Visual Activities Questionnaire; VFQ-25, Visual Function Questionnaire. highest number of significant correlations with glaucoma patients’ perceptions of their visual function (13). It is important to note that in these studies, patients presented high Esterman scores and had no associated neurological symptoms (29,30). To correlate VF loss in hemianopic patients with QoL, Wagenbreth et al divided patients into groups based on the size of the central visual field remaining intact, depicting that this factor influenced most subscales of QoL questionnaires, except for general health, eye pain, and problems while driving (F-Range 3.16–14.11; all P ,0.05). Significant differences were also observed on each subscales except for general health, eye pain, problems driving a car, and peripheral vision (F-Range 3.34–8.05; all P ,0.05) when patients were divided by the visual acuity (22). Similarly, Gall et al (24) described that VF loss and BCVA had a coordinated influence on vision-related QoL in patients with postchiasmatic lesions. However, most groups compared etiology, VF type, and VF loss area instead of MD. Our results show that the highest correlation with VFQ-25 scores were with the MD in the best eye and the average MD. Correlations between participants’ perceptions and clinical measures of visual function were in the expected e222 direction, but weaker. Hence, although the true binocular VF may affect the ability to perform daily activities more, it is possible that the QoL perceived by the patient relies more on the MD of the best eye, particularly in large VF defects such as hemianopias. Some limitations must be acknowledged, including our relatively small sample. Although most studies evaluate QoL based on self-report questionnaires and it is a widely recognized method, it is subjective and can be affected by numerous factors (31). We decided to include patients with different neurological etiologies but similar VF defects to obtain a more homogeneous sample. Although we aimed to include patients in which the visual field defect was the main neurologic defect to be able to assess its impact alone without the influence of other neurological symptoms, it is difficult to do so because parietal lobe injury, for example, may affect spatial vision too. This is one of the most complete case series with binocular VF tests, binocular approximations, and QoL analyzed simultaneously. Also, this is the first report that addresses binocular approximations compared with Esterman in these defects. Hemianopic and quadrantanopic VF defects involve a major alteration in the patients’ vision-related QoL. We believe this study takes an important step toward analyzing the Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 3. Correlation coefficients between VFQ-25 and VAQ-33 scores and visual field data in homonymous hemianopia patients Questionnaire VFQ-25 General vision Ocular pain Near activities Distance activities Social functioning Mental health Role difficulties Dependency Driving Color vision Peripheral vision VFQ-25 overall score VAQ-33 Color discrimination Glare disability Light/dark adaptation Acuity/spatial vision Depth perception Peripheral vision Visual search Visual processing speed VAQ-33 overall score MD Best Eye MD Worst Eye Average MD Esterman Score 20.55* 20.25 20.33 20.36 20.45 20.38 20.49 20.22 20.27 20.29 20.75** 20.59* 20.35 20.14 20.23 20.22 20.41 20.24 20.31 20.23 20.15 20.21 20.52* 20.43 20.41 20.18 20.27 20.28 20.44 20.30 20.37 20.23 20.20 20.24 20.62** 20.49* 0.22 20.21 0.31 0.47 0.22 0.17 0.19 20.08 0.40 0.03 0.34 0.29 0.13 0.67** 0.07 0.48 0.30 0.71** 0.28 0.48 0.50* 20.01 0.45 0.02 0.26 0.19 0.47* 0.33 0.24 0.31 0.05 0.53* 0.04 0.35 0.21 0.57* 0.32 0.31 0.38 20.37 20.30 20.25 20.44 20.19 20.30 20.01 20.43 20.37 *Statistically significant correlations are marked in bold. indicated P , 0.05, whereas **indicates P , 0.01. MD, mean defect; VAQ-33, Visual Activities Questionnaire; VFQ-25, Visual Function Questionnaire. binocular VF and identifying the effect of these VF defects on the patients’ ability to perform activities of daily living. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: E. Santos-Bueso, B. BurgosBlasco, and P. Perez-Garcia; b. Acquisition of data: B. Burgos-Blasco, P. Perez-Garcia, B. Benito-Pascual, and E. Hernandez-Garcia; c. Analysis and interpretation of data: F. Saenz-Frances and J. I. Fernandez-Vigo. Category 2: a. Drafting the manuscript: B. BurgosBlasco, P. Perez-Garcia, B. Benito-Pascual, and E. HernandezGarcia; b. Revising it for intellectual content: F. Saenz-Frances, J. I. Fernandez-Vigo, and E. Santos-Bueso. Category 3: a. Final approval of the completed manuscript: B. Burgos-Blasco, P. Perez-Garcia, B. Benito-Pascual, E. Hernandez-Garcia, F. Saenz-Frances, J. I. Fernandez-Vigo, and E. Santos-Bueso. REFERENCES 1. 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Psychological distress is associated with vision-related but not with generic quality of life in patients with visual field defects after cerebral lesions. Ment Illn. 2012;4:e12. Burgos-Blasco et al: J Neuro-Ophthalmol 2022; 42: e217-e224 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.