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Perception effects from uniocular hemianopsia

I had exophoria as a young child- and always has difficulty making depth decisions without closing one eye.

I recently had a fairly large retinal tear in my left eye.  This had been immediatelt preceded by a a posterior vitreous detachment- and several weeks prior to that a left cataract replacement.  A few weeks after the posterior retinal detachemnt, I developed a macular pucker, with a macular hole, and this was treated with laser therapy.  A  week later, I had a rather large L lateral retinal tear, treated with a vitrectomy, gas bubble, and extensive barricade lasering,  The lasering was posterior to the equator, and encroached on the macula,
I them developed an epiretinal membrane that gave me 20/400 in left eye.   The epiretinal membrane was treated with topical steroids.     Now, nine months later, my central vision is 20/20.

I have had recent visual field perimetry testing that shows Left eye hemianopsia right up to the vertical meridian.
I also have slight diplopia in L eye;   halo and flaring of bright lights, and flooding of light when light approaches my eye a an angle.
The left eye appears to have about a 2X  magnification compared to r eye.    When I alternate open eyes- the objects in the distance appear to be seen from fairly dramatically different places - much more than normal.  When I close my r eye and move my head, there appears to be a lace like pattern across my l visual field.


When I hold my index finger about six inches from my nose, and focus on a distant object, the extended finger appears as two fingers- which is normal- but the left one appears normal, and the right one appears almost transparent.  When I try to bring my eyes into a binocular view-  the images seem to fight for dominance- and there is a large area of the right visual field that appears  unreal and transparent.    
My  feeling is that the fact that almost one half of my left visual field is gone- nasally- that, by definition, that section cannot possibly have binocular vision.  There is monocular overlap from the nasal aspect of right eye- but this cannot give binocular vision.    Since my central vision is essentially normal, i can read eye charts; and since stereovison tests are based on central vision - I do pass stereovison tests.
Still, I have documented loss of half of left eye vision, and I think I am having problems with convergence and dominance- so that I still have to close one eye to make decisions about depth.  
Bottomline is I have near perfect central vision, that allows central sterovision, but one half of left eye visual field is gone.   Is this considered to be "normal" vision?     Can any experts out there explain to me what the expected problems might be with uniocular hemianopsia?    Thanks so much.
3 Responses
177275 tn?1511758844
The most important thing for you is to protect your right eye. When you have a RD in one eye especially following cataract surgery the chance of a RD in your other eye (RE) would be as high as 10-20%   So be sure your retina surgeon checks your RE regularly and if that eye develops a cataract it need close co-ordination with the retina surgeon and the cataract surgeon.

If your LE went through all of that and has 20/20 vision you are amazingly lucky and must have a very skilled retina surgeon. When the retina is detached then reattached some or all of the vision may not return. If your temporal  (lateral) retina was detached if is likely your field defect is due to the RD and it would be projected towards your nose in the LE. No defect of the RE would be expected.

If you had an exophoria previously all of this may make it more difficult for you to fuse or you might even have a exotrophia now (LE always pointing outward some).

At some point I would suggest you discuss this with your cataract surgeon OR ask for a referral to a pediatric-strabismus ophthalmologist for an exam and a determination of your binocular eye muscle status.
Avatar universal
Thank you Dr Hagan.

I have left out part of the story- so will complete it.   For about five years prior to my Left eye cataract removal, I fought a frustrating battle with fairly dense bilateral cataracts - that seemed to have started forming in my mid to late forties.     My right eye was worse than my left - but both were pretty bad.  

I also was diagnosed with glaucoma and pigment dispersion syndrome- and had been rather severely myopic my whole life.

The major major problem was that I was a very busy General/Trauma surgeon, who needed precise vision to see depth perception in open cases- but also needed to make very fine distinctions when doing laparascopy - which is a 3D operative field seen thru a 2D flat video screen.   I had to stand back often, and alternately close each eye to get some semblance of depth.

This is when I elected to have the worst cataract- the right one - removed.  This is on a background of having lifelong wandering right eye because of lack of use of it because it had such poor vision.
I dont know which eye is or was dominant.   After the right eye catarct surgery- I had clear vision in R eye, but suboptimal vision in Left eye, secondary to left eye catarct,  
At my approx one year follow up of my r eye catarct surgery, the operating surgeon noticed I had a retinal tear in superior aspect of r eye.  I immediately underwent a vitrectomy and gas bubble in R eye.    This gave me continued clear vison in R eye, with a small arc of blindness inferiorly in R eye.

As we contemplated doing a catarct removal in Left eye- I asked - based on my risk for a detachemnt on Left eye - if vitrectomy on left eye, and gas bubble, should be done at time of R catarct.    I was told that this essentially is not done- although they understood why I was asking.

We proceeded with L eye catarct.       Two weeks later, I had many flashing lights temporally in L eye, then a very dense showering of floaters - that I described as "polywogs swimming on wax paper"   In the middle of this, was a fixed large shape, that moved with eye movements.   I immediately- on a Sunday - contacted my eye surgeonm who saw me immediately in his office. He said I had a posterior vitreaous detachment, and the floating large opacificationn was a blood clot.   He asked to see me every week or two, to be sure I didnt develop a detachemnt.  about two weeks later, he said I had a macular pucker temporally in L eye, and I was seen by a retinal specialist the following day.  He treated this macular pucker with laser pexy.
About one week later, I was driving, and noticed, when I closed my left eye, that it appeared that, with my eye shut, there was a large, nasal side "light Bulb" on.  when I opened the eye, there seemed to be an encroaching dark curtain moving centrally.   I immediately callled my eye surgeon, and he basically said drive immediately to my retinal surgeon.  I did this.  He dilated my eyes, did slit lamp, and agreed that I was significantly detaching.  He took me immediately to surgery, did a vitrectomy, gas bubble, and what I undersatnd is called extensive Barricade laser.  This was posterior to the equator, and encroached on macula.
In about a moth follow up, I described a larger nasal blind spot, and that me central vision was very blurry - 20/400.  He did an OCT which showed an epiretinal membrane that, to my eyes, looked like a cross section of corrugated cardboard.   He started me on prednisone drops.
cont in next comment


8 Comments
My central acuity improved over several months.
What I first noticed was two things- since the normal eye is a great case-control for the other eye.
The visual field in my let eye looked about  between 1/3 to 1/2 smaller than my r eye.  second, when I kept my left eye open, and moved my head side to side, there was a lace like texture to my L viisual field.
Then, driving on the highway, I noticed, by alternating closing each eye - that my left eye showed cars and road signs almost twice the size of the right eye - and, I know there should be some discrepancy between what the right eye sees alone, and the left eye sees alone-  they are separated by several inches-  but mine appeared to be viewing distant objects from positions almost feet apart.
I also had slight diplopia in L eye- in that I see clear letters centrally, but just down and to the right, I see the same clear letters.   Bright lights cause flaring and halos.   Any light that strikes my eye from an angle, seems to cloud out my Left vision.
Next, I went online and saw a test where you hold your index finger six inches from your nose, and fix on a distant object. Normally, when you do this, you see "Two" index fingers of equal clarity. when I do this , the  left index finger appears normal, but the right one appears slightly down and to the right and almost transparent.
Once I had noticed this, I tried to look at normal scenes outside with both eyes- and things in the center appear normal.  Things on the left appear "peripheral" but solid and real-  but there is a large chunk of the right visual field that has this same transparent appearance.
I am guessing this has something to do with dominance, and missing part of my visual field.

I have been to several retinal specialists.   Two days ago I had formal perimetry visual field testing- where you have an automated sequence of small lights shown, and you push a button when you see a light.   The results were essentially normal on right but the left eye showed almost complete hemianopsia, right up to the midline vertical meridian.    The specialist also noticed that I had fairly profound R exophoria.


I also did standard titmus and other stereo testing that was- although slow to come to a determination - showing full 3 d capability.  My understanding is these tests are sucessful thru central vision, not any peripheral component.   ..  I had normal color blindness exam.

In summary,   The last retinal surgeon I saw, who performed these tests, and documented the complaints I had - did a very thorough job - and I thank her deeply for that.
My concern was that she also said that thier is overlap of nasal fields in anyone, so this shoud not be a problem.  I pointed out that, by definition, since I am missing the medial one half of my left eye vision- that there can not be binocular vision in this missing region.  
So, I am left to wonder:  is depth perception completely dependent on central acuity?  My reading leads me to believe there is a great deal of peripheral complonent- especially related to kinetic objects- not stationary testing material.   My second question is about eye dominannce, and the mind trying to figure out which data from which eye to accept as true.

I am not sure if it is possible to convey how difficult it is for a general surgeon -faced with a 2 d image of a 3d space-  a space filled with very edematous and distorted anatomy- to make mm by mm decisions about what is a blood vessel and what is a ligament or nerve - with the consequences of a misjudgement a very serious problem.  

I am taking this somewhat out of context - but it does portray the problem I am facing:  The retinal surgeon appears comfortable with the idea that half of my left eye visual field is gone, di not seem to address the diplopia, halos or flaring, or magnification in my left eye- and appears satisfied that my right eye nasal visual field overlaps enough with my left eye field to offer near perfect vision.

Obviously, without the actual data in hand, it is not easy to offer an opinion - but are there any readers who can begin to direct me to resources where I can further delineate this?   To me, it boils down to me missing exactly one half- medially- of my left visual field, on a background of possible distortion from a rather severe epiretinal membrane - presumably a "macular" event caused by the posterior vitreous separation.    Why do I have ghost like/transparent areas when I try to see a "stereo" view?
Any help appreciated.   Thanks so much.
I will start with a conclusion: At this point you need the services of the best eye muscle (strabismus) specialist you have access to, as you know they are often called pediatric ophthalmologists but most all do adult strabismus. You would expect the peripheral nasal visual field of the left eye to be impared as your visual field showed. Your would expect the macular images in the left eye to be worse than the right.  Actually as I said if you have a macular hole, macular edema and an epiretinal membrane and see 20/20 that is an extraordinary good result. Most patients after that type of surgery note the image is somewhat distorted (metamorphosia), larger than the normal eye (macropsia), or smaller (micropsia),   It's possible a strabismus specialist might be able to help you with prism glasses to help control your large exophoria or have you do fusion exercises. You need to move into the field of ophthalmology that is now suited for your residual problems and that would be a strabismologist. I'm sure your retina and cataract ophthalmologist would agree.
Thank you again, Dr Hagan.  The most recent retinal specialist I saw - described in last comment - is a neuro-ophthalmologist, specializing in strabismus evaluation and treatment.

For whatever reasons, she appears to be offering little more than I described above - which is, apparently, just living with it.  
I have been referred onto a retinal specialist who will consider peeling the remaining epiretinal membrane.  This may help with some of the distortion- and possibly the diplopia in L eye.  
But I still do not have an answer for the inability to form a comfortable and confident sense of depth, based on binocular vision.
Your advice has been helpful and reassuring.   I think what I am also looking for is someone with experience with these problems - to say to me something along the lines of " you are missing half of the visual field in one eye -and your brain pathways are trying to make sense of the disparate images you are getting from each eye"   "Prisms may help do this"
Up to this point, I have not heard anything of the kind.  
I have looked online for answers to my problem, but have not found anything that matches my situation.   Does anyone know of a paper that has a subject that is  something like "The effects of uniocular hemianopsia on binocular vision"     It would be very helpful to read a full discusssion of what the receptive brain pathways do with the sizeable gap in the visual field.  Additionally,   a discussion of how eye dominance may contribute.  
The final topic that is increasingly frustrating is that, as a doctor myself, I looked at the OCT images- comparing normal right, to very abnormal left.  When the epiretinal membrane was at its worst - the left eye retina looked like corrugated cardboard,  Recently, it is much improved, but, going over it with the retinal specialist, she said there are remaining stria that can be seen- but these shoudnt be noticeable.   Yet, I have this obvious lace texture, diplopia in Left eye, and halos and flaring.  To me, this seems like it would be a residul effect of the distortion from the original epiretinal membrane.   Maybe I am wrong, but it makes sense that after experiencing a very wrinkled macula - that it wouldnt be expected to just fall back into pristine original orientation.  It frustrates me- as a surgeon - to apparently have the symptoms I am describing, dismissed as insignificant.  
To me, reduced to a childlike explanantion - I should not return to operating UNLESS I can see at least nearly pefectly with EACH eye.   Doing a dificult operation, where I would explain to the patient that I can see well out of my right eye, but if I look only out of my left eye, I am missing half the field.   I think most layman would immediately understand that that would pose a problem.
I think my next step is to go to a new neuro opthalmologist.
Thanks again for your insight., and I will keep you posted on progress.
One other thought. As difficult as it is for you to do lap surgery on a 2-D screen it would be far more difficult if you were using a microscope with does give true 3-D image (e.g. surgery by ophthalmologists, ENT, Neuro, etc)
Yes - and there are infrequent occassions where I do use a microscope- or loupe magnified glasses.
I dont want to abuse your kindness in offering your expertise- but I have also been unable - after extensive searching- to find any kind of written standard for what is the minimal standard for visual ability that a general/trauma surgeon must have.
You would guess that is important. Pilots are under rigorous scrutiny.
Also, you bring up an interesting topic - that of how one sees when looking at a 2d laparascopic video screen.  There is a fairly vast literature on this - and instead of it being considered somewhat "easier" to interpret a 2d screen, when making 3d decisions; it is, in fact, much harder.   One has to constantly move the camera around, and move the tissues around, to generate 2d cues-  like change in size as you move the object or camera side to side.  A skilled laparascopic surgeon is constantly moving the camera and the tissue relative to eachother, or adjusting the angle of the scope: to gain a sense of depth.
So, one is relying on all the 2 d cues to "see" 3 dimensionally.
This is in additon to also essentialy losing the tactile cues  that open surgery allows: picking up the tissue with your hands is far superior to manipulating the tissue with thin long  metal instruments, placed thru small holes, that are sometimes under some torque to reach the tissue.
It is obviously a very very serious concern.  Another issue is that it is much easier to lose orientation when looking at a laparascopic view- compared to an open view.
I add these details to emphasize how important it is to have fully functioning vision when performing laparascopic surgery.    
Lastly, general surgery is burdened with litigation.   A surgeon does not ever want to have Perry Mason standing in front of him asking if I consider myself half blind, or a quarter blind - and why is it that pilots are tested frequently- and removed from service, but surgeons are not?   "Doctor, is there a chance you injured the vena cava because you can not see out of half of your left eye?
How would you answer that?
Thanks again.
The point I'm making is that when doing lap surgery on a 2-D screen no one has true 3-D depth perception so its not any more difficult for a one eyed surgeon than a two eye surgeon with perfect depth perception. With 3-D surgery using an operation mircroscope the one eyed surgeon or the two eyed surgeon with poor depth perception is handicaped because of the poor depth perception. I would strongly recommend your order this book: http://www.amazon.com/Singular-View-Art-Seeing-One/dp/0961463929  It from 1972 and its by a airline pilot that lost one eye in a crash and his adaptation to one eye and 2-D flat world.

I have not been involved in the residency programs in Kansas City for about 15 years but I was active at one time and also familiar with ophthalmology residency requirements. Some did ask if there was a history of poor vision in one eye, strabismus, amblyopia, reduced depth perception or any condition that might handicap perfect depth perception (stereopsis we call it). If so some would not accept the application. Also some programs tested visual acuity and stereopsis at the personal interview. With all the political correctness and alleged discrimination against physical disabilities I don't know if that is still done or not.

You are the best person to tell if you can operate safely and comfortably on your patients. If you can't you owe it to them to stop doing surgery if you can then any and all surgeons, especially in the USA, are at risk for being sued even for unavoidable complications or less than perfect results. You can ask your strabismus ophthalmologist to do a binocular visual field exam. This is a visual field test with both eyes open. Its possible your nasal field defect falls within the overlapped nasal field of the other eye. In which case you can answer honestly "No there is no chance that the field defect in my LE caused the problem because my RE could see it.
I have been thinking about what you said about viewing a laparascopic screen as strictly a 2d phenomenon - and that a one eyed surgeon could do it as well as a two eyed surgeon, because there is no 3D perception of the flat screen.

My gut tells me you are missing something.   There IS a significant difference in what a two eyed and a one eyed surgeon would perceive- and it isn't specifically 3D, but it has to do with BINOCULAR visual field. This is true even if the binocular vision is of a flat screen.
There are many perceptual pathways that have to do with motion detection; and these pathways are primarily highly sensitive in the non central macular area. They are there to tell you something is moving in to your visual field, so that you can direct your central vision to that moving object.
These movement cues are related to comparing what one eye sees compared to the other.

I think that a surgeon who is missing half of his left visual field, is also missing a chunk of these binocular visual cues - especially when things are moving.
This is true when looking at a flat screen.  I think if you say that there is nothing moving on the screen, then maybe the one eyed surgeon percieves it the same as a two eyed surgeon - but with constant movement in the screen, there is a significant difference in how the brain interprets information from both eyes, and translates it into fine motor action.
In my particular case, my brain is constantly having to choose cues from eyes that don't create a coherent picture.
I guess it seems correct to say that perception of binocular vision has evolved over a million years - with vast areas of function that we have not yet understood ; and to assume that you can lose half of one eye's visual field and this would have little effect on perception or fine motor direction, is probably missing something.
If missing one half the eye field doesn't really effect your perception of things moving on a flat screen - then does losing 90% make a difference?
Does a one eyed surgeon percieve movement in a flat screen the same as a two eyed one?  Are there perceptual cues on a flat screen that are improved by binocular vision?
I have been thinking about what you said about viewing a laparascopic screen as strictly a 2d phenomenon - and that a one eyed surgeon could do it as well as a two eyed surgeon, because there is no 3D perception of the flat screen.

My gut tells me you are missing something.   There IS a significant difference in what a two eyed and a one eyed surgeon would perceive- and it isn't specifically 3D, but it has to do with BINOCULAR visual field. This is true even if the binocular vision is of a flat screen.
There are many perceptual pathways that have to do with motion detection; and these pathways are primarily highly sensitive in the non central macular area. They are there to tell you something is moving in to your visual field, so that you can direct your central vision to that moving object.
These movement cues are related to comparing what one eye sees compared to the other.

I think that a surgeon who is missing half of his left visual field, is also missing a chunk of these binocular visual cues - especially when things are moving.
This is true when looking at a flat screen.  I think if you say that there is nothing moving on the screen, then maybe the one eyed surgeon percieves it the same as a two eyed surgeon - but with constant movement in the screen, there is a significant difference in how the brain interprets information from both eyes, and translates it into fine motor action.
In my particular case, my brain is constantly having to choose cues from eyes that don't create a coherent picture.
I guess it seems correct to say that perception of binocular vision has evolved over a million years - with vast areas of function that we have not yet understood ; and to assume that you can lose half of one eye's visual field and this would have little effect on perception or fine motor direction, is probably missing something.
If missing one half the eye field doesn't really effect your perception of things moving on a flat screen - then does losing 90% make a difference?
Does a one eyed surgeon percieve movement in a flat screen the same as a two eyed one?  Are there perceptual cues on a flat screen that are improved by binocular vision?
177275 tn?1511758844
You are missing the point and I'm not here to debate with you. Two eyes always beats one whether you're talking about depth perception, field of vision or binocular central visual acuity vs. monocular visual acuity.

In terms of the way ophthalmologists, optometrists and visual scientiests define stereopsis (depth perception) you cannot have full 3-D depth perception without two eyes being pointed at the same thing, relatively good visual acuity and a occipital lobe that can process the information and create depth perception.   real surgery done with both eyes with or without glasses or loupes is uses 3D vision so does operating through a microscope.  Flat screen high resolution surgery is not 3D surgery.

You know whether you can operate safely. If you can go about it. If you can't give up those forms of surgery you feel handicaped.

Vision is not the sole determinant. There are always one eyed athletes competing in the Olympics. I'm sure there are one eyed surgeons that can operate circles around some midiocre or poor two eyed surgeons.  I live in Kansas City.  Long time ago the KC Chiefs had an all Pro tight end named Fred Arbanas. He lost an eye in an accident. He retrained himself with one eye and was all Pro and in the Pro Bowl several years playing, and besting, two eyed professionals.

So its really about how you feel and do.  Still would recommend you get that book "A Singular View"

JCH MD
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