Abstract
PurposeSurgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown.MethodsSystematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed.ResultsSystematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay.Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5 ± 14.8 years), had a median MD of − 5.3 decibel (IQR − 3.1 to − 10.1). MD was strongly correlated with clinical severity (r = − 0.94, P < 0.0001), and were used for severity of defects cut-off values: (1) normal > − 2 dB, (2) mild − 2 dB to − 4 dB, (3) moderate − 4 to − 8 dB, (4) severe − 8 to − 17 dB, (5) very severe < − 17 dB.ConclusionSurgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.
Highlights
Non-functioning macroadenomas (NFMA) are the most prevalent pituitary macroadenomas (25%), and are often diagnosed due to pituitary insufficiency (80%) or visual impairment (85%) [1,2,3]
Studies were eligible for inclusion if: (1) the article was published in English; (2) the reported cohort consisted of patients with NFMA; (3) the reported study cohort consisted of at least 10 patients; (4) patients were treated surgically with transsphenoidal microscopic, or endoscopic techniques, or transcranial techniques; (5) visual parameters were assessed prior to and after surgery
Measurements of visual function in NFMA patients were currently limited to visual field (VF) and visual acuity (VA) [15, 16, 18, 19, 21, 23, 24, 26,27,28,29, 31, 34, 38, 40, 41, 43, 49, 50, 53, 55], with solely two studies reporting on Visual Impairment Score (VIS) and Visual Evoked Potentials (VEPs) [34, 45]
Summary
Non-functioning macroadenomas (NFMA) are the most prevalent pituitary macroadenomas (25%), and are often diagnosed due to pituitary insufficiency (80%) or visual impairment (85%) [1,2,3]. Their growth velocity is slow, but highly variable and unpredictable [4]. NFMAs with suprasellar extension will eventually compress the optic chiasm, -nerves and -tracts, and impair visual function. Following compression of the optic chiasm, the sequential order of development of visual field defects (VFD) is typical: first in the temporal upper quadrant(s), followed by the temporal lower quadrant(s). The duration and degree of pressure on the nerve fibers, for example due to growth velocity, are considered to determine the degree of loss of function [8]
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