Headache is frequently encountered in ophthalmic practice and may accompany common ocular conditions as well as neuro-ophthalmic and intracranial disease. A structured ocular examination can identify refractive error, raised intraocular pressure and papilledema, while visual field testing becomes particularly important when the pattern of visual dysfunction suggests a lesion beyond the eye.

Homonymous hemianopia localizes pathology posterior to the optic chiasm and, in adults, stroke is its most common cause. Visual field characteristics and associated neurological findings can help localize the responsible retrochiasmal lesion.[1] Acute homonymous visual field loss may therefore represent cerebral ischaemia and should prompt appropriate neuroimaging and stroke evaluation.[2] Visual problems after stroke are common and can substantially affect reading, navigation, mobility and activities of daily living.[3-6]

The present retrospective analysis was undertaken to describe the ophthalmic findings among patients presenting with headache and to highlight the diagnostic role of automated perimetry in the patient in whom a homonymous field defect led to correlation with an acute PCA-territory infarct.

MATERIALS AND METHODS

This was a retrospective descriptive analysis of 50 patients evaluated for headache in the Department of Ophthalmology, M.B.S. Hospital, associated with Government Medical College, Kota, Rajasthan, during 2026. Clinical records were reviewed in a de-identified manner. Written informed consent for publication of the individual patient clinical information and images was obtained, and identifying information was excluded from the manuscript.

Patients presenting with headache underwent clinical and ophthalmic evaluation. The available records were reviewed for the principal ophthalmic or neuro-ophthalmic finding. Patients with raised intraocular pressure underwent further disc and gonioscopic evaluation, while patients with raised intracranial pressure/papilledema were referred for urgent neuroimaging and neurological/neuro-ophthalmological assessment. In the patient with visual field loss, neurological assessment included level of consciousness, orientation, Glasgow Coma Scale, pupillary responses, motor and sensory examination, language assessment and cognitive screening. Corrected visual acuity was recorded in both eyes. Automated perimetry was performed using a Zeiss Humphrey Field Analyzer with a Central 24-2 threshold test, SITA-Standard strategy, size III white stimulus and 31.5-asb background. NCCT of the head, electrocardiography, complete blood count, lipid profile, renal and liver biochemical parameters, coagulation studies and available infectious screening investigations were reviewed.

Data were summarized descriptively using frequencies and percentages for the 50-patient headache cohort. No inferential statistical testing was undertaken. Rehabilitation-relevant assessment in the patient with PCA infarction included functional vision, mobility and balance, activities of daily living, cognition, motor and sensory examination, and communication. Compensatory visual scanning, environmental modification, occupational-therapy-based ADL retraining, field-adapted mobility training and safety education were explained.

RESULTS

Among 50 patients evaluated for headache in the Department of Ophthalmology, refractive error was the most frequent finding in 42 (84%) patients, followed by raised intraocular pressure in 5 (10%), raised intracranial pressure/papilledema in 2 (4%), and homonymous visual field loss in 1 (2%). Refractive errors were managed with optical correction. Patients with raised intraocular pressure underwent further disc and gonioscopic evaluation and were managed according to the underlying ocular diagnosis. Patients with raised intracranial pressure/papilledema were referred for urgent neuroimaging and neurological/neuro-ophthalmological evaluation. The distribution of findings is shown in Table 1.

Table 1: Distribution of principal findings among patients presenting with headache (n=50)

The patient with visual field loss underwent fundus examination, confrontation testing, NCCT, automated perimetry and OCT. Corrected visual acuity was 6/24 in the right eye and 6/36 in the left eye. Automated Humphrey 24-2 field maps demonstrated extensive loss affecting corresponding hemifields in both eyes, producing a homonymous pattern consistent with a retrochiasmal lesion. NCCT demonstrated a large wedge-shaped hypodense area with blurring of the grey-white matter junction in the left medial temporo-occipital lobe, reported as a likely acute infarct in the left PCA territory. An ill-defined area of encephalomalacia with gliosis in the right frontal lobe was interpreted as an old insult. No midline shift or intra-axial or extra-axial haemorrhage was identified.

FIGURES:

Figure 1&2: Automated Humphrey 24-2 visual field examination left (1) and right (2) eye, demonstrating marked homonymous field loss.

On history-taking and neurological examination, this patient was a 53-year-old chronic smoker who was conscious with altered behaviour, oriented to time, place and person, and had a Glasgow Coma Scale score of E4V5M6. Pupils were bilaterally reactive to light. Motor and sensory examinations were normal, no aphasia or dysarthria was documented, and the MMSE score was 30. Electrocardiography showed sinus rhythm at approximately 65 beats/minute with machine-reported nonspecific ST-junctional depression and an overall borderline classification. The principal vascular-risk-related laboratory abnormalities were total cholesterol 245 mg/dL, LDL cholesterol 187 mg/dL and HDL cholesterol 28 mg/dL. Other available laboratory findings are summarized in Table 2.

Table 2: Selected laboratory investigations in the patient with PCA-territory infarction

The documented rehabilitation assessment was normal for the recorded standardized domains. Cognitive screening was normal (MMSE 30), and no motor, sensory, aphasic or dysarthric deficit was recorded. Visual compensatory strategies and safety-oriented rehabilitation measures were explained.

DISCUSSION

The principal finding of this retrospective series was that most patients presenting with headache had common ophthalmic abnormalities, particularly refractive error. Nevertheless, one of 50 patients (2%) had a homonymous visual field defect associated with an acute PCA-territory infarct. This observation underscores the value of looking beyond common ocular causes when the visual complaint or field pattern is not adequately explained by routine examination.

In the patient with PCA infarction, automated perimetry and neuroimaging showed strong anatomical concordance. A homonymous field pattern localizes the deficit posterior to the optic chiasm, and stroke is the most frequent cause of homonymous hemianopia in adults.[1] The left medial temporo-occipital lesion on NCCT was therefore consistent with the perimetric localization. Prospective stroke cohorts have demonstrated that visual field loss is a clinically important post-stroke deficit and may be under-recognized without systematic visual assessment.[3,4]

The patient was a chronic smoker and had elevated total cholesterol and LDL cholesterol with low HDL cholesterol. These findings reinforce the need for vascular risk assessment in patients with cerebral ischaemia, although this descriptive dataset cannot establish causal associations. Current acute ischaemic stroke guidance emphasizes timely evaluation and evidence-based management once stroke is suspected.[2]

Post-stroke visual field loss can interfere with reading, obstacle detection, navigation, driving, occupational performance and community mobility.[1,3] Rehabilitation should therefore consider functional vision even when limb motor examination is normal. Evidence for specific visual-field interventions remains limited, but compensatory scanning strategies and individualized rehabilitation approaches are commonly evaluated and may be considered according to functional needs.[5,6]

Stroke remains an important cause of morbidity and disability. The retained regional reference by Gupta et al. describes recurrent-stroke patients evaluated at a tertiary care hospital in Rajasthan and provides locally relevant clinical context.[7] Early diagnosis and treatment can definitely help such patients.

This study has several limitations. It was retrospective, involved only 50 patients presenting to a single ophthalmology department, and the available records did not support detailed analysis of headache phenotype, duration, demographic distribution or associations between clinical variables. Only one patient had homonymous visual field loss/PCA infarction, precluding inferential analysis of predictors or outcomes. MRI/vascular imaging and longitudinal visual-field follow-up were not available in the supplied record. Larger prospective studies with standardized headache characterization, ophthalmic examination and neuroimaging criteria are required.

CONCLUSION

Among patients presenting with headache, refractive error was the most frequent ophthalmic finding, while raised intraocular pressure and raised intracranial pressure/papilledema were less common. Importantly, automated visual field assessment identified homonymous visual field loss in one patient, with NCCT demonstrating an acute left PCA-territory infarct. Careful ophthalmic assessment of headache, including formal perimetry when clinically indicated, can provide valuable localization and may uncover serious retrochiasmal neurological disease despite relatively preserved motor and sensory function.

AUTHOR CONTRIBUTIONS

Dr Nahar Singh supervised and guided the clinical work and manuscript preparation. Dr Priyank Sharma performed the neurological examination. Dr Anushka Gupta acquired the clinical data, performed the ophthalmological assessment and drafted the manuscript. All authors reviewed and approved the final manuscript.

ACKNOWLEDGEMENT

The authors thank the clinical teams, faculty, and mentors of the department of Ophthalmology, General Medicine, Neurology, Neurosurgery, Radiodiagnosis, and Central Lab at MBS Hospital and GMC, Kota, involved in the evaluation and care of the patient. The authors also acknowledge Dr. Shailendra Vashistha (Assistant Professor, Transplant Immunology HLA Lab, Dept of IHTM, GMC, Kota) and the VAssist Research team (www.thevassist.com) for their contribution in manuscript editing and technical support in submission process.

CONFLICT OF INTEREST: None declared.

SOURCE OF FUNDING: Nil.

REFERENCES

1. Goodwin D. Homonymous hemianopia: Challenges and solutions. Clin Ophthalmol. 2014;8:1919-1927. doi:10.2147/OPTH.S59452.
2. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211.
3. Rowe FJ, Wright D, Brand D, Jackson C, Harrison S, Maan T, et al. A prospective profile of visual field loss following stroke: Prevalence, type, rehabilitation, and outcome. Biomed Res Int. 2013;2013:719096. doi:10.1155/2013/719096.
4. Rowe FJ, Hepworth LR, Howard C, Hanna KL, Cheyne CP, Currie J. High incidence and prevalence of visual problems after acute stroke: An epidemiology study with implications for service delivery. PLoS One. 2019;14(3):e0213035. doi:10.1371/journal.pone.0213035.
5. Pollock A, Hazelton C, Rowe FJ, Jonuscheit S, Kernohan A, Angilley J, et al. Interventions for visual field defects in people with stroke. Cochrane Database Syst Rev. 2019;5(5):CD008388. doi:10.1002/14651858.CD008388.pub3.
6. Hanna KL, Hepworth LR, Rowe FJ. The treatment methods for post-stroke visual impairment: A systematic review. Brain Behav. 2017;7(5):e00682. doi:10.1002/brb3.682.
7. Gupta S, Singh S, Maheshwari D, Sardana V, Bhushan B. Analysis of various sleep architecture parameters using polysomnography among patients with recurrent stroke: A cross-sectional study at a tertiary care hospital in Rajasthan. Int J Med Pharm Res. 2025;6(5):1958-66. doi:10.5281/zenodo.17510043.