Nasal visual field involvement has never been documented in migraine-linked scintillating scotomata. In a dedicated search of migraine literature spanning almost 50 years, I have never found a single reference to distribution of scintillating scotoma of migraine homonymously into or across the nasal visual fields.
With automated visual field testing, non-glaucomatous spontaneous self-resolving visual field defects are not seen in the nasal half of the visual field. Even with binocular scintillating scotomata, homonymous distribution has not been recorded. doi:
10.1016/j.ophtha.2016.01.002. Because migraine attacks can also be bilateral, it is incorrect to simplistically assume that a bilateral / binocular scintillating scotoma, neuroanatomically, is homonymously distributed.
Neurologists and ophthalmologists do not ever clinically evaluate the SS of migraine prospectively as per the guidelines of Hupp, Kline, and Corbett (1989), even when given the rarest-of-rare chance.
I present the first prospective minute-by-minute clinical-physical examination of the the progressive scintillating scotoma of migraine, confined to the temporal visual field of the left eye with distracting visual blurring, drawn by hand by the patient herself absolutely without any suggestion, as the positive scotoma progressed and resolved completely over 120 minutes. Pupils were bilaterally constricted 2-3 mm, with no light reflex elicited. No artistic or computer-linked touch-up of the drawing is involved. The scintillating scotoma in this case was accompanied with unusually severe ipsilateral fronto-temporal throbbing headache that lasted for 4-5 days. She has been having migraine headache attacks since 18 years of age, but this the first attack of scintillating scotoma that she has experienced.
The long trek back to neurological / medical sense and sensibility, reason and logic, and biological plausibility, that I began 3 decades ago (1989) gathers further strength. A non-homonymous positive visual experience / hallucination absolutely cannot be of brain visual cortical origin through cortical spreading depression / spreading depression / brain neuronal hyperexcitability. The retina is, unarguably, the source of origin of the pathognomonic scintillating scotoma of migraine.
Sparing of the nasal visual field with SS of migraine is dependent on an idiosyncrasy of the functional anatomy of the eye, clues for which will come from the association of migraine with connective tissue disease, viz., the Ehler-Danlos syndrome, hypermobility type, as detailed in 1990 Rolex Awards, Spirit of Enterprise, Bern, Switzerland, in the Marfan Syndrome-like blue-sclera of eye of migraineurs - a project at ResearchGate.
Hupp, Kline, and Corbett's masterpiece and clinically invaluable methodology of differential diagnosis between brain and retinal visual phenomena (1989) has never been quoted or reproduced in Neuro-Ophthalmological, Neurological, or Ophthalmologic medical journals, to the detriment of the science of migraine. This clinical insight must form an essential component of post-graduate / Board Examinations in these fields.
A sea change in perception in the science of migraine is just around the corner.
The Migraine Code, with its infinite variations, just like the 43 quintillion combinations of the original 3x3x3 Rubik's Cube, the postmodern Gordian knot, is well within firm grasp of human comprehension.
Comments, including scathing / scalding critiques, are welcome.
ORCID ID: https://orcid.org/0000-0002-6770-5916
07-July-2023