SCOTOMA

Definition An area of partial alteration in the field of vision consisting of a partially

diminished or entirely degenerated visual acuity that is surrounded by a field of
normal – or relatively well-preserved – vision. A scotoma can occur in one eye
or both, in the center or at the outer edges of the visual field, and can occur
alone or there can be several. It can be temporary, but in the majority of cases,
it is permanent.

Under normal daylight (photopic) conditions, the smallest or least intense

visible objects are only seen in the central region of the visual field. In the
periphery, objects must be larger or more intense to be identified. A normal
visual field extends approximately 100° temporally (laterally), 60° nasally, 60°
superiorly, and 70° inferiorly [2]. A physiologic scotoma (a blind spot) exists at
15° temporally where the optic nerve leaves the eye. Definitive location varies
slightly on an individual basis. The average blind spot is 7.5° in diameter,
vertically centered 1.5° below the horizontal meridian. For dim night lighting
(scotopic) conditions, the mid periphery is the most sensitive region of the
visual field.

Types  Scintillating scotoma: This scotoma appears as a localized region of

reduced vision that is edged by shimmering colored lights. This is the type
of scotoma that occurs before the onset of a migraine headache.
 Central scotoma: This scotoma is perhaps the most troublesome type. It is a
dark spot in the center of the field of vision. The remaining visual field
remains normal, often causing the patient to focus on the periphery, or
outer boundaries, of the field. They may have trouble looking at colors and
details, while they can see best in dim-lit regions. This makes daily activities
such as reading and driving very difficult.
 Peripheral scotoma: This type of scotoma is a dark spot along the edges of
the field of vision. They may see well when looking at colors and details.
They may have the best vision in well-lit regions. They may bump into
objects while walking due to an inability to see them.
 Hemianopic scotoma: With this type of scotoma, half of the visual field is
affected by the dark spot. This can occur on either side of the center, and
can affect one or both eyes, but usually affects them both. This is also
sometimes called homonymous hemianopsia.
 Paracentral scotoma: This scotoma is a dark spot that occurs near, but not
in, the central visual field.
 Bilateral scotoma: This type of scotoma appears in both eyes and is caused
by some type of brain tumor or growth. Usually a pituitary tumor starts to
compress the optic chiasm and leads to a bi-temporal hemicentral
scotomatous hemianopia.It is relatively rare.
Etiology  Demyelinating disease such as multiple sclerosis (retrobulbar neuritis),
 Toxic substances such as methyl alcohol, ethambutol and quinine,
 Nutritional deficiencies,
 Vascular blockages either in the retina or in the optic nerve,
 Glaucoma,
 Damage to nerve fiber layer in the retina (seen as cotton wool spots) due
to hypertension,
 Stroke or other brain injury,
 Macular degeneration, often associated with aging.
 Scintillating scotoma is a common visual aura in migraine.
 Scotomata due to tumors such as those arising from the pituitary gland,
which may compress the optic nerve or interfere with its blood supply
 A result of a corrective surgical operation in the eye or an ocular infection
that has left a scar in the eye. The infection could have occurred while the
sufferer was still in the womb of his or her mother. Retinitis Pigmentosa, a
degenerative hereditary condition of the retina that is characterized by
various problems like: night blindness, changes in pigment within the
retina, & eventual loss of vision
 In a pregnant woman, scotomata can present as a symptom of severe
preeclampsia, a form of pregnancy-induced hypertension.
 Result of the increased intracranial pressure that occurs in malignant
hypertension.
 Use of aminoglycoside antibiotics mainly by Streptomycin.

Symptoms  One or more dark or light areas or even blurred regions in the visual field
 An increased requirement of greater contrast and illumination while
reading.
 Difficulties in perceiving some colors.
 Difficult to know the identity of people by looking at their faces.

Diagnosis  Anamnesis: symptoms of patients, any other conditions or or any eye

surgery that they may have recently suffered or gone through.
 Physical examination of the eye: visual field test
Confrontation visual field testing: The doctor faces the patient and asks the
patient look straight ahead. The doctor will present stationary or moving
targets in the patient's peripheral (side) visual fields. While maintaining a
straight-ahead gaze, the patient lets the doctor know when he/she can see
the target in the peripheral vision. The target may be a small disc on a
stick, but most commonly the target is the doctor's hand holding up one or
two fingers.
 Amsler grid
Detect vision problems resulting from damage to the macula (the central
part of the retina) or the optic nerve. The damage may be caused by
macular degeneration or other eye diseases.
 Steps
1. Test your eyes under normal room lighting used for reading.
2. Wear eyeglasses you normally wear for reading (even if you wear only
store-bought reading glasses.
3. Hold the Amsler grid approximately 14 to 16 inches from your eyes.
4. Test each eye separately: Cup your hand over one eye while testing the
other eye.
5. Keep your eye focused on the dot in the center of the grid and answer
these questions:
o Do any of the lines in the grid appear wavy, blurred or
distorted?
o Do all the boxes in the grid look square and the same size?
o Are there any "holes" (missing areas) or dark areas in the grid?
o Can you see all corners and sides of the grid (while keeping
your eye on the central dot)?
6. Switch to the other eye and repeat.

 Perimetry
1. Static automated perimetry (such as Octopus or the Humphrey Field
Analyzer): Pinpoint flashes of light of varying size and brightness are
projected within a large white bowl. The patient is asked to look at the
center of the bowl and press a button each time a light is seen in the
peripheral vision. The machine collects the data and uses
sophisticated software to analyze the results.
2. Kinetic perimetry (such as Goldmann perimeter): Moving targets of
various light sizes and intensities are shown and the patient indicates
when they become visible in the peripheral vision. The resulting data
is used to map the full visual field. The full, normal range of the visual
field extends approximately 120° vertically and a nearly 160°
horizontally.
3. Frequency doubling perimetry: This test utilizes varying intensities of a
flickering image to analyze the visual field. It is particularly useful in
detecting early glaucoma field loss.

 Horizontal eccentricity
Refers to the horizontal axis, measured in degrees, along the visual field. The
blind spot extends from an eccentricity d1 to
eccentricity d2 in temporal direction from the fovea. The size of the blind spot
can be calculated as

Differential Diagnosis  Glaucoma

 Optic Neuritis
  Retinitis
 Vascular disorders
 Retinal degeneration
 Carotid Artery Thrombosis
 Optic Atrophy
 Ophthalmodynamometry

Treatment If the scotoma is on the outer edges of your vision, it usually does not cause
severe vision problems. If you have a scotoma in your central vision, it cannot
be corrected or treated with glasses, contact lenses, or surgery. Your provider
will recommend that you use aids to support your decreased vision.

Tools that can be used to help include:

 Large-number phone keypads and watch faces
 Filters to reduce glare on computer screens
 "Talking" clocks or scales
 Audio books, magazines, or newspapers or machines that "read" printed
material aloud in a computer voice
 Using large type printed books or enlarging the type size in an eReader
(electronic devices such as iPads, Nooks, or Kindle)
 Personal computer hardware such as lighted keyboards, large type, and
software that magnifies screens and converts text to speech for both
computers and mobile phones
 Closed CCTV systems that use video cameras and large TV screens to
enlarge reading material, medicine bottles, or pictures
 Magnifying eyeglasses, hand-held magnifiers, or stand magnifiers to
enlarge your reading material or other objects
HEMIANOPIA & GANGGUAN LAPANG PANDANG
ANOPSIA Lesi pada nervus optikus akan menyebabkan hilangnya penglihatan monokular
atau disebut anopsia (no.1) pada mata yang disarafinya. Hal ini disebabkan
karena penyumbatan arteri centralis retina yang mendarahi retina tanpa
kolateral, ataupun arteri karotis interna yang akan bercabang menjadi arteri
oftalmika yang kemudian menjadi arteri centralis retina. Kebutaan tersebut
terjadi tiba-tiba dan disebut amaurosis fugax.
HEMIANOPSIA Lesi pada bagian lateral kiasma optikum akan menyebabkan hemianopsia binasal
BINASAL (no.2).
Kelainan seperti ini banyak disebabkan oleh lesi khiasma, seperti tumor dan kista
intrasellar, erosi dari processus clinoid seperti yang terjadi dengan tumor atau
aneurisma dorsal dari sella tursica, kalsifikasi di antara atau di atas sella tursika
seperti yang terjadi dengan kista dan aneurisma kraniofaringioma, dan juga pada
meningioma suprasellar. Juga dapat disebabkan oleh trauma dan tumor pada
regio kiasma.

HEMIANOPSIA Lesi pada bagian medial kiasma akan menghilangkan medan penglihatan
BITEMPORAL temporal yang disebut hemianopsia bitemporal (no.3).
Hemianopsia bitemporal bisa didapatkan pada kista suprasellar. Bisa juga
ditemukan pada pasien dengan tumor pituitari tapi bersifat predominan
parasentral. Pada adenoma pituitari juga bisa terjadi kebutaan atau anopsia pada
salah satu mata dan hemianopsia temporal pada mata yang lainnya.

HEMIANOPSIA Lesi pada traktus optikus akan menyebabkan hemianopsa homonim

HOMONIM kontralateral (no.4). Serabut-serabut dari retina pada bagian temporal akan
KONTRALATERAL rusak, bersamaan dengan serabut dari bagian nasal retina mata yang lain yang
bersilangan.

HEMIANOPSIA Lesi pada bagian posterior radiasio optika akan mengakibatkan hemianopsia
HOMONIM TANPA homonim yang sama dan sebangun dengan mengecualikan penglihatan makular
MAKULA TERLIBAT (no.5).

QUADROANOPSIA Lesi pada radisio optika bagian lateral akan menyebabkan quadroanopsia
SUPERIOR superior homonim kontralateral (no.6). Quadroanopsia atau kuadranopia
HOMONIM biasanya terjadi pada lesi yang terdapat pada bagian temporo-parietal.
KONTRALATERAL

QUADROANOPSIA Lesi pada radiasio optika bagian medial akan menyebabkan quadroanopsia
INFERIOR inferior homonim kontralateral (no.7). Quadroanopsia atau kuadranopia
HOMONIM biasanya terjadi pada lesi yang terdapat pada bagian temporo-parietal.
KONTRALATERAL