Journal of Neuro-Ophthalmology, December 1998, Volume 18, Issue 4

When Fighting Makes You See Black Holes Instead of Stars

A young boxer developed a left homonymous hemianopia immediately after a blow to the head. A magnetic resonance image showed a lesion in the right lateral geniculata region that was consistent with a previous cerebral hemorrhage and was likely the cause of the visual field defect.

Journal of Neuro- Ophtlmlmology 18( 4): 255- 257, 1998. & 1998 Lippincott Williams & Wilkins, Philadelphia When Fighting Makes You See Black Holes Instead of Stars Gregory Kosmorsky, D. o., and Raymond R. Lancione, Jr., M. D. A young boxer developed a left homonymous hemianopia im­mediately after a blow to the head. A magnetic resonance im­age showed a lesion in the right lateral geniculata region that was consistent with a previous cerebral hemorrhage and was likely the cause of the visual field defect. Key Words: Homonymous hemianopia- Traumatic brain in­jury- Lateral geniculate body. CASE REPORT A 19- year- old boxer came to the Cleveland Clinic Foundation with difficulty seeing in the left hemifield. The patient was otherwise healthy and took no medica­tions. He had no ocular medical history. He was a com­petitive boxer and during a fateful fight was stuck hard in the head by a right hook. After getting up slowly from the mat, he noted that the left side of his vision seemed different and he had trouble seeing his opponent. His neurologic history was of interest in that approxi­mately 2 years before this injury, the patient had awak­ened with a numb sensation in his left foot. During the next 6 months, the sensation had proceeded up to the Manuscript received June 26, 1998; accepted June 29, 1998. From the Division of Ophthalmology, the Cleveland Clinic Founda­tion, Cleveland, Ohio. Address correspondence to Gregory Kosmorsky, D. O., Cleveland Clinic Foundation A- 31, 9500 Euclid Ave., Cleveland, OH 44195- 5024. level of his mid left thorax. The patient sought the opin­ions of a neurologist and an ophthalmologist before pre­sentation for his visual loss and neurologic symptoms. He had two cerebral magnetic resonance imaging scans and he was thought to have suffered a stroke. However, no explanation could be offered for the incongruous left homonymous hemianopia that he showed on visual field testing, because the stroke seemed to be isolated the pos­terior thalamic region and did not involve the optic ra­diations or any visual cortical components. Similarly, likewise, no explanation could be offered for the neuro­logic symptoms. Evaluation for his sensory symptoms included a lumbar puncture that yielded normal spinal fluid results including a normal Tourtellotte's analysis and the absence of oligoclonal bands; no cervical mag­netic resonance image ( MR1) was obtained. When seen at the Cleveland Clinic 1 month after the initial injury. His visual acuity was 20/ 20- 2 OD and 20/ 20 OS without correction. Pupils were 5 mm with equal reactions, and he had no afferent pupillary defect. He was orthophoric at distance without correction. Versions were full in both eyes. Confrontational testing of visual fields showed a defect consistent with left homonymous inferior quadrantanopsia. Applanation tonometry read­ings were 14 in both eyes. Slit lamp findings were un­remarkable. The optic nerve heads were found to have temporal pallor OU. The remainder of the dilated fundus examination yielded findings within normal limits. Neu- <** FIG. 1. Goldman visual fields showing mildly incongruous left homonymous hemianopia. 255 C E N T R H L 24 2 T H R E S H O L D TEST 2 T H R E S H O L D TE8T S1IMUS I I I . WITE, 8CKWD 3 t . S RS8 BLIHO SPBI CHECK SIZE OFF STSHHGY F i l l THRESHOLD BIRTHDATE 11- 22- 77 DRTE 09- 22- 97 FIKHTIOH T » « I HHTBAL 10 ! 61 « - 6 « ? TIME « I J G I » AN 8K USED DS OCX DEG PUPIL DIMETER 5.8 M W 26/ 2E HO - 17.+ 5 DB P ( i. V. PSO 16.59 DS p { e.; x SF Z. S9 DO Pi iX [ PSD 16. ZG D8 P ( B. 5J C E N T R H L 24 NOME STIKXtlS I I I . UHIIE. KKOT 31.1 IBS BLIHO SPOT CHECK SIZE OFF FIXflTlOK rfiKET STRMEtr FILL THRESHOLD RX USEO DS ACE » FIX8T1MI LDSSES f B FH. 5EPDS ER108S HZ FALSE NEC EWORS 1/ 1 NESTING RSKEO Z84 RIGHT 11- 22- 77 DRTE 09- 22- 97 m. ID H l l - t » 7 TME Wi « H9 W W DEC PUPIL DlfMTEt S. B Ml * 2B/ Zf - 23 - 33 - 34 - 33 - 3J • 34 • • • • • • • • • • • 37 - 13 Z8 - 27 30 - 17 -! - 5 - 1 - J - 4 t - 2 - 2 - 3 3S - 3J - 3 - 2 - 6 - S Jt - 34 .1 - 8 - 4 33 - 33 - S - Z • • • • • • • * ••• • • ;; - PMKBILITt STUeOLS COPYRIGHT 1994 .9 41 50 2 . 5 36 40 8 3 . 2 31 35 2 3 10 26 36 79 32 21 25 r- AV- Jl II ll II 1 2 5 ! r00 IB 20 9 1S 15 1000 S 10 3 1 62 5 1DOOO < 0 CLEVELAND CLINIC HOSP. EYE INSTIUTE 9560 EUCLID AVE. CLEVELANO, OHIO 44135 21S- 444- 2020 I HUMPHREY INSTRUMENTS rsi; A CfiRL ZEISS COMPANY COPYRIGHT 1994 . a 41 2 . 5 36 40 e 3 . 2 31 35 :,;;;;; 2 5 ~ 10 26 3 8 79 2 3 mrwwjo 251 100 16 20 7 94 3 1 6 11 15 Tsll 6 10 3 l 6 2 3 " 10000 S0 CLEVELAND CLINIC HOSP. EYE INSTIUTE 9500 EUCLID AVE. CLEVELRND. OHIO 44195 216- 444- 2020 HUMPHREY INSTRUMENTS rj A CARL ZEISS COMPANY FIG. 2. Humphrey visual field showing complete left homonymous hemianopia. FIG. 3. Axial T2- weighted magnetic resonance im­age sections: ( A) Area of encephalomalacia in the region of the right lateral geniculate body ( arrow), ( B) axial pathologic section of the brain ( taken from Melville and Hanaway, Atlas of the Human Brain. Philadelphia: Lea & Febiger, 1970) with 34 identi­fying the lateral geniculate nucleus, and ( C) a more dorsal section showing encephalomalacia of the right thalamic region ( arrow). GENICULATE HEMORRHAGE DUE TO CLOSED HEAD TRAUMA 257 1 24- 2 Thru ha Id Tdt en Nonitwi CiieBllndirot on t i f H t i Ctnlrjl o n t o u lU 6/ 14 Sllftjlllll I I I . Ulill BtcltrKindi 31.) KB S t r t t l l ) ! SlIA- Slwidird I D I £ 6 1 0 - 8 2 37 PuMI D i i M i i r i ! , N Uiiuil feuitm 18/ 15 RXi OS DC 18 ! B 16 < B te ( 8 2G 25 ( 8 ( B < B o u 26 28 ? 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Humphrey visual field showing incongruous left homonymous hemianopia. rologic examination was significant for numbness to pin­prick at the T6 spinal level and was more prominent on the left. Goldman visual field testing ( Fig. 1) indicated a left quadrantic homonymous hemianopia. Humphrey vi­sual field testing ( Fig. 2) revealed a left hemifield defect with some incongruity. Magnetic resonance image of the brain ( Fig. 3A- 3C) showed neuronal loss in the area of the right lateral geniculate body, indicative of previous hemorrhage in this region. The patient was seen in fol­low- up 1 month later. At that time, his visual field defect had improved to a quadrantic defect and was clearly incongruous ( Fig. 4). Reinterpretation of the scans revealed an area of en-cephalomalacia in the right posterior thalamic region; however, this abnormality extended interiorly into the lateral subthalamic region and involved the lateral genic­ulate region, accounting for the visual field abnormalities ( Fig. 4). The patient was thought to have had a traumatic right lateral geniculate hemorrhage during a competitive boxing match. He was further thought to have a lesion of the T6 spinal cord level, most consistent with a de-myelinating lesion, probably unrelated to his ocular find­ings. However, no spinal cord mass or signal consistent with demyelination was identified on subsequent imag­ing. This case illustrates a rare lateral geniculate hemor­rhage induced by closed- head trauma. J Neuro- Ophthalmol, Vol. IS, No. 4, 1998 [VBtraumaticvisualloss]