Homonymous hemianopia as the presenting sign of posterior cortical atrophy

A 56-year-old man reported 1 year of progressive decline in the vision of both eyes, left more than right. He had difficulty explaining his symptoms. Although he could clearly see the letters of text when reading, he struggled to verbalise and understand the content. He took amitriptyline and sertraline for anxiety and depression. Visual acuity was 6/12 (20/40) in each eye with normal ocular examination. He read simple material in a slow, halting fashion and made several errors. He scored 20/30 on mini-mental state examination. Formal visual field testing identified an incongruous left homonymous defect with good reliability (figure 1A).

We arranged an urgent MR scan of the brain and orbits with contrast and with diffusion-weighted imaging, to exclude a right retro-chiasmal visual pathway lesion. However, this showed only prominent sulci in the parieto-occipital region compared with the frontotemporal region (figure 1B,C). We suspected posterior cortical atrophy…

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