Lesions of the Visual Pathway:

1. Lesions of the optic nerve. These are characterisedby marked loss of vision or complete
blindness on the affected side associated with abolition of the directlight reflex on the ipsilateral
side and consensual onthe contralateral side. Near (accommodation) reflex ispresent. Common
causes of optic nerve lesions are:optic atrophy, traumatic avulsion of the optic nerve,indirect
optic neuropathy and acute optic neuritis.
2. Lesions through proximal part of the optic nerve.Salient features of such lesions are:
Ipsilateralblindness, contralateral hemianopia and abolition ofdirect light reflex on the affected
side and consensualon the contralateral side. Near reflex is intact.
3. Sagittal (central) lesions of the chiasma. Theseare characterised by bitemporal hemianopia
andbitemporal hemianopic paralysis of pupillary reflexes.These usually lead to partial
descending opticatrophy. Common causes of central chiasmal lesionare: suprasellar aneurysms,
tumours of pituitarygland, craniopharyngioma, suprasellar meningiomaand glioma of third
ventricle, third ventriculardilatation due to obstructive hydrocephalus andchronic chiasmal
arachnoiditis.
4. Lateral chiasmal lesions. Salient features of suchlesions are binasal hemianopia associated
with binasalhemianopic paralysis of the pupillary reflexes. Theseusually lead to partial
descending optic atrophy.Common causes of such lesions are distension of
third ventricle causing pressure on each side of thechiasma and atheroma of the carotids or
posteriorcommunicating arteries.
5. Lesions of optic tract. These are characterised byincongruous homonymous hemianopia
associatedwith contralateral hemianopic pupillary reaction(Wernicke’s reaction). These lesions
usually lead to
partial descending optic atrophy and may be
associated with contralateral third nerve paralysis andipsilateral hemiplegia. Common causes of
optic tractlesions are syphilitic meningitis or gumma,tuberculosis and tumours of optic thalamus
andaneurysms of superior cerebellar or posterior cerebral arteries.
6. Lesions of lateral geniculate body. These producehomonymous hemianopia with sparing of
pupillaryreflexes, and may end in partial optic atrophy.
7. Lesions of optic radiations. Their features varydepending upon the site of lesion. Involvement
oftotal optic radiations produce complete homonymoushemianopia (sometimes sparing the
macula). Inferior
quadrantic hemianopia (pie on the floor) occurs inlesions of parietal lobe (containing superior
fibres ofoptic radiations). Superior quadrantic hemianopia (piein the sky) may occur following
lesions of thetemporal lobe (containing inferior fibres of opticradiations). Pupillary reactions are
normal as the fibresof the light reflex leave the optic tracts to synapse inthe superior colliculi.
Lesions of optic radiations donot produce optic atrophy, as the second orderneurons (optic nerve
fibres) synapse in the lateralgeniculate body. Common lesions of the opticradiations include
vascular occlusions, primary andsecondary tumours, and trauma.
8. Lesions of the visual cortex. Congruous
homonymous hemianopia (usually sparing the macula,is a feature of occlusion of posterior
cerebral arterysupplying the anterior part of occipital cortex.