NIHSS Visual Field Testing 3 — Questions and Answers
Question 1: The NIHSS visual field item uses confrontation testing. How many fingers does the examiner typically use when testing each quadrant?
- One finger per quadrant
- Two fingers simultaneously in opposing quadrants (Correct answer)
- All five fingers waved together
- A penlight flash
Correct answer: Two fingers simultaneously in opposing quadrants
The standard technique is simultaneous finger counting in upper and lower quadrants to detect field defects efficiently.
Question 2: A patient correctly detects finger movement in the left visual field but misses it every time it is presented simultaneously with the right. Without simultaneous presentation, the left field is intact. What does this finding suggest?
- Left hemianopia
- Right hemianopia
- Left visual extinction/neglect (Correct answer)
- Bilateral blindness
Correct answer: Left visual extinction/neglect
Extinction only on simultaneous bilateral stimulation indicates visual neglect (extinction), not a true field cut.
Question 3: On NIHSS item 3, a patient has a right superior quadrantanopia ('pie in the sky' defect). What score is assigned?
- 0
- 1 (Correct answer)
- 2
- 3
Correct answer: 1
A quadrantanopia is a partial field defect and scores 1 on NIHSS item 3.
Question 4: Why is it important to test each eye's visual fields from directly in front during NIHSS assessment rather than from the side?
- To prevent the patient from turning their head and compensating
- To ensure fixation is maintained and peripheral fields are tested symmetrically (Correct answer)
- Because the NIHSS protocol only tests central vision
- To avoid any examiners' fingers entering the blind spot
Correct answer: To ensure fixation is maintained and peripheral fields are tested symmetrically
Testing from in front while the patient fixates on the examiner's nose ensures symmetric evaluation of all four quadrants without head-turn compensation.
Question 5: A patient scores 1 on NIHSS item 3 due to left inferior quadrantanopia after an acute stroke. Which cortical area is most likely affected?
- Right frontal lobe
- Right parietal-occipital junction (superior optic radiation) (Correct answer)
- Right temporal lobe (Meyer's loop)
- Left occipital pole
Correct answer: Right parietal-occipital junction (superior optic radiation)
Inferior quadrantanopia ('pie in the floor') results from damage to the superior optic radiations in the parietal-occipital region.
Question 6: During NIHSS assessment, the examiner tests visual fields before assessing ocular movements. Why is this order clinically significant?
- It has no clinical significance; the order is arbitrary
- Eye movement deficits may confound visual field results if gaze is deviated (Correct answer)
- Visual field testing requires the patient to move their eyes first
- Item 3 always comes before item 2 to ensure compliance
Correct answer: Eye movement deficits may confound visual field results if gaze is deviated
Knowing about gaze deviation (item 2) before scoring fields helps the examiner interpret apparent field deficits that may actually reflect gaze palsy, but the structured NIHSS order is designed so fields are tested with eyes in primary position.
Question 7: A stroke patient can only perceive hand motion centrally in both eyes and has no peripheral vision. What is the NIHSS item 3 score?
- 1 — partial loss
- 2 — complete hemianopia
- 3 — bilateral blindness (Correct answer)
- 0 — normal
Correct answer: 3 — bilateral blindness
Bilateral visual field loss resulting in near-total blindness is scored 3, the maximum for NIHSS item 3.
NIHSS Visual Field Testing 3
The NIHSS visual field item uses confrontation testing.
How many fingers does the examiner typically use when testing each quadrant?