A 65-year-old man presents with bilateral progressive visual field loss affecting only the upper visual fields ('altitudinal' loss), with normal optic disc appearance. OCT shows thinning of the inferior macular ganglion cell layer. Which condition is most consistent with bilateral inferior arcuate visual field loss respecting the horizontal meridian?
- A Advanced bilateral primary open-angle glaucoma with inferior rim thinning ✓
- B Pituitary adenoma compressing the chiasm
- C Bilateral occipital lobe infarcts (bilateral homonymous hemianopia)
- D Leber's hereditary optic neuropathy
Explanation
In advanced POAG, retinal nerve fibre layer (RNFL) loss preferentially affects the superior and inferior poles of the optic disc early because the superior and inferior arcuate RNFL bundles are most vulnerable. Inferior RNFL loss produces superior arcuate or altitudinal visual field defects that respect the horizontal meridian (because the arcuate fibres straddle the horizontal raphe). Bilateral superior field loss with inferior RNFL thinning on OCT, in the absence of visual pathway lesion, is a hallmark of advanced glaucoma. Pituitary adenoma causes bitemporal hemianopia; occipital infarcts cause bilateral homonymous hemianopia.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.