Available from: https://www.ncbi.nlm.nih.gov/books/NBK545213/. 2. According to research, the majority of recovery occurs within the first 60 days after the initial event, and recovery after six months is highly unlikely. The patient was referred to his primary care physician with a request for an MRI with contrast of the area in question, to be performed within 24 to 48 hours. Impact of visual field loss in health-related quality of life in glaucoma: the Los Angeles Latino Eye Study. Such changes, among others, may indicate a cerebrovascular accident (stroke). 2. It is most commonly caused by brain tumors, subdural hematoma, or hydrocephalus. To fully appreciate the potential underlying causes for various visual field defects, it is important to have a working knowledge of the anatomy of the visual system. WebThe location (and frequency) of lesions causing superior quadrantanopias was occipital lobe (83%), parietal lobe (3%), and temporal lobe (13%). If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Glaucoma is the leading cause of field loss across all adult age groups when tested using automated threshold or supra-threshold perimetry. complaints. Slightly more than half the nasal pupil pathway fibers cross at the chiasm, so significant defects anterior to the chiasm cause an RAPD. Pupils were normally reactive and ocular motilities were unrestricted. Current Opinion in Ophthalmology, 14(6), 325331. The optic nerve projects from the lamina cribrosa of the scleral canal, through the optic canal, to the optic chiasm. Optic radiations exit dorsally from the LGN into two separate fascicles: Inferior (known as Meyers loop) and Superior (known as the parietal fascicles). This includes tighter control of comorbidities such as diabetes, hypertension, hypercholesterolemia, hyperlipidemia and obesity. Definition (NCI) Blurred vision is the loss of visual acuity (sharpness of vision) resulting in a loss of ability to see small details. Our thanks to the following individuals for helping to inspire this article: Mr. Matthew Hennen (SCO 16), Dr. Leah Stevens and Dr. Robert Goodwin (via ODs on Facebook). The visual association cortex (Brodmann's area 19) projects through the cortico-tectal tract to the superior colliculus and pretectal nucleus. If patient is blind from any cause, score 3. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Coleman AL, Cummings SR, Yu F, et al. Knowledge of the functional anatomy of neurological pathways is essential in the interpretation of examination results. 7. Stimulation (e.g., from an irritative lesion) causes contralateral deviation of the eyes (i.e., away from the lesion). The chiasm lies in the suprasellar cistern above the sella turcica, and is surrounded by the hypothalamus superiorly and the infundibulum and pituitary gland inferiorly[3]. It represents damage to the inferior optic radiating fibers (Meyers loop). (E) Sixth-nerve palsy, right eye. He was alert and oriented, had a normal gait and displayed no affective abnormalities. Damage to the right parietal lobe can produce contralateral neglect. Unexplained visual acuity loss. This visual field defect is characteristic of damage to Meyer's loop on the left side of the brain. 17. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. History of head trauma. Time is critical! Homonymous superior quadrantanopia, also called pie in the sky, causes a field deficit in the superior field of both eyes for the same side. So macular vision can be spared when only one of the major cerebral vessel distributions is affected. Fishman GA, Bozbeyoglu S, Massof RW, et al. Examining visual field defects in the paedriatric population exposed to vigabatrin. THE At the junction of the optic nerve and the chiasm, there are two different types of fibers on the optic nerve that can be affected: the nasal crossing fibers and the temporal non-crossing fibers. When patients display other neurological symptoms, an immediate referral is required. One exception to neurology referral is a patient with visual field loss that you suspect is psychogenic in origin. It receives input from the contralateral frontal eye field. G. Papilledema (choked disk) is noninflammatory congestion of the optic disk as a result of increased intracranial pressure. Are there other neurological signs? These field defects will cross neither the vertical midline nor the horizontal midline. Causes of incident visual field loss in a general elderly population: the Rotterdam Study. The pressure cone forces the parahippocampal uncus through the tentorial incisure. 1. (CN II) and an efferent limb (CN III). Goodwin D. Homonymous hemianopia: challenges and solutions. This presents with loss of both temporal fields and is due to compression of the bilateral The etiologies of retrochiasmal lesions are different between adults and children. Scotomas that change can be considered transient, so they are more likely vascular in origin. Invest Ophthalmol Vis Sci 2006 Dec;47(12):5303-9. If you find nothing, neuroimaging is essential; place emphasis on the retro-orbital space, the optic nerves, chiasm and optic tracts. In: StatPearls [Internet]. 10. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. (2018). (/) Destructive lesion of the right frontal eye field. B. Ultimately, this patient was diagnosed with neurosyphilis, and was treated with penicillin. Our patient was found to have an incomplete, moderately congruous, left homonymous hemianopia, denser above than below the horizontal midline. It includes the following structures: A. Ganglion cells of the retina, which project bilaterally to the pretectal nuclei, B. Webquadrantanopia A loss of vision in a quarter of the visual field. Wilkins, 1997, p 261. Traumatic chiasmal syndrome: A meta-analysis. Most commonly, the nasal crossing fibers are affected, manifesting with a monocular temporal field defect in the ipsilateral eye. Note that the defect in the right (asymptomatic) eye strongly respects the vertical midline. 14. Additionally, a comprehensive neurological evaluation was requested to rule out any additional compromise. In essence, the more the field loss in one eye appears to be a carbon copy of the other, the greater the level of congruity. Although the patients chief complaint seemed to indicate a retinal etiology, testing quickly confirmed this was a neuro-ophthalmic event. b. Transection of both lingual gyri causes an upper altitudinal hemianopia (al-titudinopia). 2. Complete homonymous hemianopias have no localizing value, except to say that they are post-chiasmal.1. Double simultaneous stimulation is performed at this point. Note that the defect in the right (asymptomatic) eye strongly respects the vertical midline. 1. The pattern of the visual field defect is also more indicative of stroke than other intracranial abnormalities, such as traumatic brain injury, cerebral hemorrhage or compressive tumor. The patient underwent neuroradiological evaluation, and a craniopharyngioma was found. Ultimately, an automated field analysis was performed, demonstrating a dense, homonymous hemianopic defect of the left visual field, denser above than below the horizontal midline. Nerve fibers originating in the nasal retina cross at the level of the optic chiasm, traveling with contralateral temporal fibers to the lateral geniculate nucleus where they synapse. The presence or absence of coincident flashing lights, floaters, dyschromatopsia, eye pain, headache, vertigo, diplopia, metamorphopsia or other seemingly unrelated symptoms will often direct your management. Further RecommendationsThe patient was referred to his primary care physician with a request for an MRI with contrast of the area in question, to be performed within 24 to 48 hours. The incidence of visual field loss increases with age. (F) Paralysis of upward gaze and convergence (Parinauds syndrome). WebPost-chiasmal lesions result in homonymous field defects, i.e., affecting the same side (right or left) of the visual field and respecting the vertical midline. Nearly one out of every 20 people past age 55 has visual field loss that is significant enough to impair daily functioning. It can be associated with a lesion of an optic radiation. The junctional scotoma (see Junctional Scotoma and Junctional Scotoma of Traquair) manifests as a central scotoma in the ipsilateral eye and a superior temporal visual field defect in the contralateral eye. Multidisciplinary evaluation and treatment including orbital or neurosurgery may be necessary depending on the underlying lesion producing the visual field defect. Association of visual field loss and mobility performance in older adults: Salisbury Eye Evaluation Study. Meschia JF, Bushnell C, Boden-Albala B, et al. WebConclusion : Unilateral quadrantanopia appears to have been caused by pituitary tumor with intratumor hemorrhage, or pituitary apoplexy, that compressed the posterior portion of optic chiasm upwards. Kasten E, Bunzenthal U, Sabel BA. Are there any other unassociated symptoms? [4], Homonymous inferior quadrantanopia is a loss of vision in the same lower quadrant of visual field in both eyes whereas a homonymous superior quadrantanopia is a loss of vision in the same upper quadrant of visual field in both eyes. Visual radiation to lingual gyrus Visual radiation to cuneus. Interruption of this pathway at any level causes ipsilateral Horner's syndrome. As they reach the occipital lobe (the primary visual cortex), the superior and inferior fibers are reunited. To understand these field defects, its necessary to know how the eye processes the visual field. right. E. The lateral geniculate body is a six-layered nucleus. A referral to a retinologist, neurologist or internist may be required. Figure 17-3. Remember: Nearly half of the nerve fibers cross at the optic chiasm, so the loss of visual field on one side is quite different than loss of vision in one eye. An anisocoria produces a small relative afferent pupillary defect in the eye with the smaller pupil. This is considered a bitemporal visual field defect despite the extension into the superior nasal quadrant in the left field.How quickly does the referral need to be made? O.S. 2009;37(1):30-53. Glaucoma, branch retinal artery occlusion, anterior ischemic optic neuropathy. Webunilateral blindness or enucleation, visual fields in the remaining eye are scored. It occurs in the days or hours leading up to profound vision loss. If there is a complete lesion or compression at the optic nerve, patients may experience total monocular vision loss in the affected eye. 5. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. D. The ciliary ganglion, which gives rise to postganglionic parasympathetic fibers. It also receives fibers from the ipsilateral temporal hemiretina and the contralateral nasal hemiretina. 11. It usually does not alter visual acuity, but it may cause bilateral enlarged blind spots. Sometimes, however, the most obvious diagnosis is not the correct one. O.S. 5. C. The subcortical center for lateral conjugate gaze is located in the abducent nucleus of the pons (Figure 17-5). Convergence remains intact (inset). The bottom line: From a clinical standpoint, a right positive RAPD means that you should be looking for a problem in the right retina and/or optic nerve. The visual field defect from a chiasmal lesion thus depends on which fibers are compressed. Chiasmal syndromes. The visual field defect seen in the chiasmal syndrome is typically a bitemporal hemianopsia. 6th Edition. 2. 21. Vellayan Mookan, L., Thomas, P. A., & Harwani, A. These fields are cortical centers for involuntary (smooth) pursuit and tracking movements. What if there is no ocular cause for the field loss? [5], A lesion affecting one side of the temporal lobe may cause damage to the inferior optic radiations (known as the temporal pathway or Meyer's loop) which can lead to superior quadrantanopia on the contralateral side of both eyes (colloquially referred to as "pie in the sky"); if the superior optic radiations (parietal pathway) are lesioned, the visual loss occurs on the inferior contralateral side of both eyes and is referred to as an inferior quadrantanopia. (10) Upper altitudinal hemianopia as a result of bilateral destruction of the lingual gyri. WebQuadrantanopia: vision loss in a quarter of the visual field of both eyes; Unilateral vision field loss indicates a disorder of a structure anterior to the optic chiasm. If an APD is present, it will nearly always become much more obvious with the addition of the ND filter.18. The visual pathway from optic chiasm to striate cortex. The History Makes the Diagnosis Anatomy of the Visual Pathways. WebIt can be caused by a lesion, particularly, in the temporal and parietal lobes although it is more commonly associated with occipital lobe lesions. One study found a five-fold increase of visual field loss between ages 55 and 80. Bitemporal field loss. The diagnosis can be made with the swinging flashlight test (see Figure 17-4A). Occlude the abnormal eye and shine the light in the normal eye. bank of calcarine sulcus, Figure 17-2. In general, most mass lesions compressing the visual system require surgery both for diagnostic (pathologic confirmation) and therapeutic (relieve mass effect) indications. Quadrantanopia, quadrantanopsia, refers to an anopia (loss of vision) affecting a quarter of the visual field. The hypothalamus. Patients with residual field deficit following stroke may benefit from vision rehabilitation, including such elements as prismatic correction and compensatory training to improve visual search abilities. https://doi.org/10.1097/00055735-200312000-00002, Lee AG, Johnson MC, Policeni BA, Smoker WR. Neuro-Ophthalmology (Amsterdam: Aeolus Press. Miller, Neil R., Newman, Nancy J. eds. Fixed scotomas usually signal retinal, optic nerve, or neurological involvement.16. Ed: Rosen ES, Eustace P, Thompson HS, et al. This review discusses conditions (other than glaucoma) that can cause symptomatic visual field loss, and it includes a practical guide to ancillary testing and referral of these patients. At a visit in our clinic several months prior, vision O.S. Visual fields are below. If patient is blind from any cause, score 3. This is often from an anterior chiasmal lesion[6]. Nerve fibers originating in the nasal retina cross at the level of the optic chiasm, traveling with contralateral temporal fibers to the lateral geniculate nucleus where they synapse. OCT-A Shows Microvascular Glaucomatous Damage, 10-2 Visual Field Testing: A Tool for All Glaucoma Stages, AI-assisted Retinal Screening Shows Promise. contralateral homonymous superior quadrantanopia: 'pie in the sky' visual field defect (due to disruption of Meyer's loop which dips into the temporal lobe) deficits arising from unilateral lesions involving the non-dominant hemisphere: contralateral homonymous superior quadrantanopia; prosopagnosia: failure to recognise faces The pattern of the visual field defect is also more indicative of stroke than other intracranial abnormalities, such as traumatic brain injury, cerebral hemorrhage or compressive tumor.2 The patient was advised that he had likely suffered an isolated stroke which caused him to experience vision loss. This presents with loss of both temporal fields and is due to compression of the bilateral decussating nasal fibers at the chiasm, since the nasal fibers correspond with the temporal visual fields[5]. He was alert and oriented, had a normal gait and displayed no affective abnormalities. The sufferer is able to detect light within the damaged visual field. Often, patients first notice visual symptoms accidentally, even if the problem has been long-standing. It may have a Post-geniculate fibers split into superior and inferior pathways, traveling through the parietal and temporal lobes, respectively, as they course posteriorly in the brain. Am J Ophthalmol 2007 Jun;143(6):1013-23. Pupillary dilation and its effects on automated perimetry results. This is considered a bitemporal visual field defect despite the extension into the superior nasal quadrant in the left field. Occasionally, patients will spontaneously recover vision in the affected field within the first three months after the brain injury; however, vision loss remaining after this period of spontaneous recovery is traditionally thought to be permanent, certain companies now claim to be able to induce recovery of vision after this three-month period. This complex includes the following structures: 1. 6. Visual neglect (also called hemispatial neglect or unilateral O.S. So, if the patient says, I cant see on the left side, you need more clarification before you develop a short list of differential diagnoses. For pathology affecting the post-chiasmal pathways, the accepted convention is that greater congruity is associated with more posteriorly located lesions. THE VISUAL PATHWAY (Figure 17-1) includes the following structures. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. Next, hold the ND filter over the suspect eye and repeat the test. Common cause(s) All rights reserved. B. Occipital eye fields are located in Brodmann's areas 18 and 19 of the occipital lobes. Congruency in homonymous hemianopia. Double simultaneous stimulation is performed at this point. Due to the abrupt onset of symptoms, we suspected a cerebrovascular accident affecting the posterior optic radiations or anterior occipital cortex. 2. Patient with MLF syndrome cannot adduct the eye on attempted lateral conjugate gaze, and has nystagmus in abducting eye. D. Horner's syndrome is caused by transection of the oculosyuipatheik; pathway at any level (see IV). White light comparison testing showed a 25% sensitivity in the left eye as compared to the right. However, the etiology is less commonly from a congenital, traumatic, vascular, inflammatory, infectious, demyelinating, and infiltrative source[5]. The response in the stimulated eye is called the direct pupillary light reflex. Type of field defect 1. It regulates voluntary (saccadic) eye movements. (G) Fourth-nerve palsy, right eye. WebLoss of vision in a quarter section of the visual field of one or both eyes; if bilateral, it may be homonymous or heteronymous, binasal or bitemporal, or crossed, for example, involving Quickly switch the occluder to the normal eye, and shine the light in the abnormal eye. Journal of Glaucoma, 22 Suppl 5 Suppl 1, Proceedings of the 18th Annual Optic Nerve Rescue and Restoration Think Tank: Glaucoma and the Central Nervous System September 1617, 2011 New York, NY Sponsored by The Glaucoma Foundation (TGF), S2S7. His visual acuity recovered fully, but his visual fields only partially recovered. C. Contralateral homonymous hemianopia is caused by compression of the posterior cerebral artery, which irrigates the visual cortex. Retrochiasmal Disorders. In: Zhang X, Kedar S, Lynn MJ, et al: Homonymous hemianopias: clinical-anatomic correlations in 904 cases. left, O.D. If you think you see an RAPD but you arent sure, verify your findings. Perimetric homonymous visual field loss post-stroke. (7) Right hemianopia with macular sparing. As the corticospinal motor tracts are often involved as well causing contralateral hemiparesis[13]. An Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. Looking right Looking left Eyes converged. In such cases, refer the patient to a neurologistor better yet, a neuro-ophthalmologist. 1. Relations of the left upper and left lower divisions of the geniculocalcarine tract to the lateral ventricle and calcarine sulcus. The rostral Edinger-Westphal nucleus, which mediates pupillary constriction through the ciliary ganglion. The amount of compensatory movements and the frequency with which they are employed is believed to be dependent on the cognitive demands of the task; when the task is so difficult that the subject's spatial memory is no longer sufficient to keep track of everything, patients are more likely to employ compensatory behavior of biasing their gaze to the afflicted side. Lesions of the chiasmmost commonly pituitary gland tumors or craniopharyngiomasresult in bitemporal, heteronymous field defects. A 55-year-old black male with a history of Type 2 diabetes and hypertension presented urgently for evaluation. His visual acuity recovered fully, but his visual fields only partially recovered. The associated features like aphasia and hallucinations will help to further localize lesions to the temporal lobe[13]. WebA visual world of someone with normal vision. (A) Relative afferent (Marcus Gunn) pupil, left eye. 1. At the chiasm, the temporal retinal nerve fibers remain uncrossed on the same side and travel ipsilaterally on the optic tract. Layers 1, 4, and 6 receive crossed fibers; layers 2, 3, and 5 receive uncrossed fibers. https://doi.org/10.1097/IJG.0b013e3182934978, Takahashi, M., Goseki, T., Ishikawa, H., Hiroyasu, G., Hirasawa, K., & Shoji, N. (2018). By Alan G. Kabat, OD, and Joseph W. Sowka, OD. J AAPOS 2006; 10: pp. 18. Pelak VS, Dubin M, Whitney E. Homonymous hemianopia: a critical analysis of optical devices, compensatory training, and NovaVision. 1. WebSudden unilateral quadrantanopia caused by retinal diseases often has characteristic presentations, such as acute onset and severe visual acuity defect. Vascular and ischemic etiologies (i.e hemorrhage, aneurysm) are more frequent for adults, whereas neoplasms are more common for children[9][10]. The lower division (see Figure 17-2) loops from the lateral geniculate body anteriorly (Meyers loop), then posteriorly, to terminate in the lower bank of the calcarine sulcus, the lingual gyrus. and 20/200 O.S. 3. If patient is blind from any cause, score 3. Kudrna GR, Stanley MA, Remington LA. Kedar S, Zhang X, Lynn MJ, et al. One study found a five-fold increase of visual field loss between ages 55 and 80.8, An even more surprising finding: In one study of 61 post-stroke patients suffering from homonymous visual field loss (as determined by Humphrey visual field analysis), none were aware of the visual field loss.9 Also, only two of those 61 patients were identified as having field loss using the National Institutes of Health Stroke Scale (NIHSS) technique, which is a finger-counting confrontation visual field screening. 530 Walnut Street, Philadelphia, Pennsylvania 19106 USA; 351 West Camden Street, Baltimore, Maryland 21201-2436 USA:Lippincott Williams & Wilkins; 2005. 2007 May;143(5):772-80. These fibers innervate the sphincter muscle of the iris. Optic chiasm field defects Lesions at the optic chiasm are characterised by bitemporal hemianopia. F. Transtentorial (uncal) herniation occurs as a result of increased supra tentorial pressure, which is commonly caused by a brain tumor or hematoma (subdural or epidural). Imaging for neuro-ophthalmic and orbital disease - a review. Ophthalmology 2008 Jun;115(6):941-48.e1. D. The optic tract contains fibers from the ipsilateral temporal hemiretina and the contralateral nasal hemiretina. In Ophthalmology (Fifth Edition, pp. 2. Recovery from poststroke visual impairment: evidence from a clinical trials resource. It occurs in syphilis and diabetes. Any complaint of a fixed missing spot in the visual field (monocular or binocular). It causes medial rectus palsy on attempted lateral conjugate gaze and monocular horizontal nystagmus in the abducting eye. Reproduction in whole or in part without permission is prohibited. Understand that the presence of anisocoria doesnt create a clinically observable pseudo-APD until anisocoria of 2mm or more is present.19 So, dont dismiss subtle or trace RAPD responses to a 0.5mm anisocoria. The optic chiasm is the point where the two optic nerves meet[3]. White light comparison testing showed a 25% sensitivity in the left eye as compared to the right. Optic nerve and significant retinal disease in one eye can create color vision disturbances and positive RAPD results in that eye. Besides your normal history and examination sequence, ask: Is the field loss in one eye, or is it on one side of the field? (6) Right lower quadrantanopia. There was a pronounced RAPD in the left eye with reduced color vision (1/14 plates) in the left eye only. HVr6}WX0. A Roadmap to the BrainVisual field testing provides insight into the integrity of the visual pathway. Transection of the lower division (B) results in right upper homonymous quadrantanopia. Another way to help confirm subtle RAPDs is to purchase an inexpensive 0.3 log unit neutral density (ND) filter. Otherwise, many of these cases are considered to be urgencies rather than emergencies, and require referral within a few days to a week. There was a pronounced RAPD in the left eye with reduced color vision (1/14 plates) in the left eye only. WebThe syndrome of visuospatial neglect is a common consequence of unilateral brain injury. Smoking cessation (including avoidance of second-hand smoke), a low-fat diet and regular exercise are also typically encouraged. In pre-chiasmal field defects, anopia is unilateral. Ultimately, this patient was diagnosed with neurosyphilis, and was treated with penicillin. Such knowledge will enhance proper triage of these often-critical patients. If you can confirm that the visual field is not organic in nature, careful consideration for a referral to a psychologist or psychiatrist is indicated. The caudal Edinger-Westphal nucleus, which mediates contraction of the ciliary muscle. II. 4. Sample visual field* THE PUPILLARY DILATION PATHWAY (Figure 17 4) is mediated by the sympathetic division of the autonomic nervous system. Common and/or Classic Visual Field Patterns and Their Causes 15. A. Ganglion cells of the retina form the optic nerve [cranial nerve (CN) II]. A 46-year-old white male complained of blurry vision and a missing spot of vision in his left eye for approximately eight months. Lastly, the junctional scotoma of Traquair (see Junctional Scotoma and Junctional Scotoma of Traquair) may occur. Lesions of the medial longitudinal fasciculus (MLF) between the abducent and oculomotor nuclei result in medial rectus palsy on attempted lateral conjugate gaze and horizontal nystagmus in the abducting eye. Headache and photophobia have also been known symptoms[4]. Examination revealed corrected acuity of 20/25 OU. Did the loss occur suddenly or gradually? Philadelphia: F.A. Damage to the optic radiations Invest Ophthalmol Vis Sci 2007 Oct;48(10):4445-50. Human Neuropsychology, Sixth Edition, p.361; Worth Publishers (2008), William J. Weiner: Neurology for the Non-Neurologist, p.526; Lippincott Williams & Wilkins (July 2010), Rehabilitation for Homonymous Hemianopia and Quadrantanopia, Visual Fields in Brain Injury - Hemianopsia.net Everything you need to know about Hemianopsia, "Hemianopic and quadrantanopic field loss, eye and head movements, and driving", Thygeson's superficial punctate keratopathy, Chronic progressive external ophthalmoplegia, https://en.wikipedia.org/w/index.php?title=Quadrantanopia&oldid=1139493898, Short description is different from Wikidata, Articles with unsourced statements from December 2020, Creative Commons Attribution-ShareAlike License 3.0. https://doi.org/10.1016/B978-0-323-52819-1.00237-1, Yoshihara MK, Lui F. Neuroanatomy, Bitemporal Hemianopsia. A normal scan sometimes turns out to be not so normal when re-evaluated with more critical parameters! Clin Ophthalmol. Sparing or involvement of the monocular temporal crescent localizes to the occipital lobe[13]. The clinical manifestations of orbital tumors may include gaze-evoked amaurosis (due to reduction in the flow of blood to the optic nerve and retina), proptosis, optic disc swelling (direct compression of the optic nerve), optociliary shunt (actually retinochoroidal venous collateral) vessels, and choroidal folds[13]. J Am Optom Assoc 1995 Nov;66(11):675-80. Pupils were normally reactive and ocular motilities were unrestricted.
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