A 67-year-old patient with visual field loss and dysphagia

by Yosef Laviv, MD and Ekkehard Kasper, MD PhD

Department of Surgery, Division of Neurosurgery; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston, MA USA
67-year-old, right-handed male, with past medical history (PMH) of alcohol and tobacco abuse, hypertension, hyperlipidemia, coronary arterial disease, gastroesophageal reflux disease, prostate cancer, CVAs (multiple lacunar infarcts involving the brainstem, cerebellar hemispheres and vermis) and patent foramen ovale, presents with dysphagia, cough and weight loss.

Barium swallow test revealed a long segment of fixed esophageal narrowing involving the distal half of the esophagus with mucosal ulceration concerning for a neaoplasm. An esophago-gastro-duodenoscopy (EGD) showed severe esophagitis with an irregular mass at 25cm. Brushings have returned positive for squamous cell carcinoma.

One day after the EGD procedure, the patient presents with new onset, severe headaches and visual loss. Per history, the patient woke up a week prior with impaired vision in his right field. He had difficulties reading the end of sentences and attending to objects on his right side.  His vision worsened over 4 days until he couldn’t see anything on his right side. Ophthalmology examination revealed 20/80 acuity bilaterally and a new right homonymous hemianopsia (prior fields from 2014 were full). No papilledema was evident.  Patient was sent to the emergency department (ED) for further evaluation.

* 1. What is the differential diagnosis for the patient’s new visual field loss, based on his PMH and present illness?