Improvement Of Visual Field Defects Research Articles

Sublabial transmaxillary approach to the inferior aspect of the orbit.

The objective was to demonstrate the surgical steps and outcomes of the sublabial transmaxillary microsurgical approach with endoscopic assistance to treat lesions in the inferior aspect of the orbit, as well as to describe the use of patient-specific 3D models to facilitate surgical preparation and improve experience with the technique. The authors' study evaluated data from patients who underwent an endoscope-assisted sublabial transmaxillary approach for inferior orbital lesions. For 2 patients, 3D models were created for preoperative planning and assessment of the approach. Surgical steps comprised osteotomy to access the maxillary sinus, bony resection of the orbital floor, opening of the periorbital fascia, and dissecting and removing the lesion, followed by closure. The neuroendoscope was used to inspect the surgical cavity between each step. The study included 5 patients with varying visual field defects and proptosis who underwent the sublabial transmaxillary microsurgical approach with endoscopic assistance. Complete resection was achieved in all, and all patients reported improvement in visual field defects and proptosis after the procedure. No complications were observed except for transient unilateral maxillary edema noted around the incision site in 3 patients during the early postoperative period, which resolved within a few days. Histopathological examination confirmed the diagnosis of cavernous malformation in all patients. The sublabial transmaxillary approach is a direct and safe method to resect cavernous malformations at the inferior aspect of the orbit. It reduces the risk of complications associated with lateral, transcranial, and transnasal approaches that may cross critical structures. The microsurgical approach provides the benefit of two-handed dissection for lesions embedded in orbital fat, which can be challenging because of adhesions to surrounding tissues. The use of 3D models can facilitate surgical planning and enhance familiarity with the approach.

Visual field improvement after endoscopic transsphenoidal surgery in patients with pituitary adenoma.

To analyze and predict the possibility of visual field (VF) recovery after endoscopic transsphenoidal surgery (ETSS) in patients with pituitary adenoma, we investigated the factors affecting the improvement of the visual field defect (VFD) and built a nomogram predictive model based on these risk factors. We further investigated specific recovery regions of VF associated with the improvement of VFD. The clinical data of patients who underwent ETSS for pituitary adenomas at a single center between the January 2021 and April 2022 were retrospectively analyzed. Univariate and multivariate analyses were used to determine the predictive factors affecting the improvement in the VF defect and specific recovery regions in patients with pituitary adenomas after ETSS. We enrolled 28 patients (56 eyes) who were hospitalized at our institution. Four clinical features, including compression of the optic chiasm, preoperative mean defect (MD), diffuse defect, and duration of the visual symptom, were chosen from the least absolute shrinkage and selection operator regression analysis to establish the predictive nomogram. The nomogram's area under the curve (AUC) was 0.912, indicating a good degree of differentiation. A calibration plot was used to evaluate the predictive model's calibration, and a decision curve was used to evaluate its clinical application value. The VF defects were improved in the 270-300° range (270-300: RR = 361.00, 95% CI: 21.01-6,202.41). We developed a predictive nomogram model based on significant visual field improvement-associated factors after ETSS in patients with pituitary adenoma. Postoperative visual field improvement is likely to begin at 270-300° in the inferior temporal quadrant. This improvement would enable personalized counselling for individual patients by precisely predicting the visual field recovery after surgery.

Dopamine agonist for the rapid improvement of visual field defects in giant and macro-prolactinomas

To evaluate effect of first-line dopamine agonist (DA) therapy as an alternative to surgery for visual field defect (VFD) recovery in giant and macro-prolactinoma. In this retrospective study, 125 patients with giant and macro-prolactinoma, except those with a history of previous surgery or radiotherapy, were evaluated. Those who underwent visual field examinations using the Humphrey Visual Field analyser upon initial assessment and after treatment were included for analysis. Twelve patients with VFD were included. The effects of DA therapy on both VFD and tumor size were evaluated within the first three months. There were twelve patients analysed: three females and nine males, five giant and seven macroprolactinomas; eight patients received cabergoline (CAB) and four patients received bromocriptine (BRC). The mean adenoma diameter was 35±13mm (range 15-60), and the mean PRL level was 3,523ng/dL (range 312-11,703). Eight patients (67%) complained of blurred vision, while four patients (33%) reported no visual symptoms. After a median duration of three weeks, the VFD completely resolved in ten patients (83%) but only partially improved in two (17%). The mean initial doses of CAB and BRC that provided VFD improvement were 0.5±0.2mg/week and 6.3±1.4mg/day, respectively. After a mean duration of 2.2±0.9months, the mean decrease in adenoma size was 43.6±24.5% (range 10-95%). The use of DA as a first-line treatment for at least one month before deciding on surgery is recommended in giant and macro-prolactinomas with VFD. Surgery should be considered only in cases with DA resistance or persistent visual impairment despite medical therapy.

Predictive value of OCT and MRI for postoperative visual recovery in patients with chiasmal compressive lesions.

We aimed to investigate the predictive value of retinal thickness measured by optical coherence tomography (OCT) and mass biometrics measured using magnetic resonance image (MRI) for visual recovery after surgery for removal of a mass compressing the optic chiasm. Consecutive patients who showed typical temporal visual field defect (VFD) with respect to the vertical meridian due to a chiasmal compressive mass and who underwent mass removal surgery were recruited. Ophthalmic examination was performed preoperatively and postoperatively. Retinal thickness was measured by the Cirrus OCT. The height and size of the mass and suprasellar extension (SSE) in both the sagittal and coronal planes were evaluated. Patients were divided into two groups based on the improvement in VFD (mean deviation [MD] change ≥ 5 dB: group R; others: group NR) and clinical characteristics were compared. Fifteen patients were included in the study. Eight (53.3%) patients were allocated into group R and others (7 patients, 46.7%) into group NR. Age, sex, initial visual acuity, initial MD was not different between the two groups. The retinal thicknesses were not different while tumor height, volume, and both sagittal and coronal SSE were significantly different between the two groups. (p = 0.029, 0.014, <0.001, and <0.001, respectively) All MRI parameters showed significant predictive value for the degree of MD recovery. MRI showed better predictive value than OCT in predicting postoperative VFD recovery in patients with temporal VFDs due to chiasmal compressive disorder.

Avoidance and Improvement in Visual Field Defect After Surgery for Metastatic Brain Tumors in the Parietal and the Occipital Lobe

Visual field defects occasionally occur secondary to tumors in the parietal and the occipital lobes. The aim of this study was to analyze the efficacy of improvement in hemianopsia after surgery for metastatic brain tumors involving or adjacent to the optic radiation (OR). The study included 49 patients with brain metastasis in the parietal and occipital lobes in the present study. Preoperative and postoperative neurological assessments included visual field, Mini-Mental State Examination, and Karnofsky performance scale. Of 49 patients, 33 (67.3%) presented with preoperative homonymous hemianopsia. Of these 33 patients, the visual field was improved postoperatively in 17 patients (51.5%). In all patients regardless of preoperative hemianopsia, postoperative visual fields did not deteriorate. Tractography demonstrated that the OR was split by the tumor (n= 6) and fanning of fibers expanded along the lateral side of the tumor (n= 11). All tumors were removed via surgical access toward the medial side of the tumor. Gross total resection was achieved in most tumors in the group with visual improvement (n= 16/17; 94.1%). Improvement in the visual field was attributed to tumor location in the subcortical white matter, removal rate of the tumor, and higher postoperative Karnofsky performance scale score. The OR tended to deviate to the lateral side of the tumor in the parieto-occipital junction. The postoperative visual field improved even in cases of an occipital tumor. Based on the present study, total resection via an appropriate surgical route should be considered to preserve the OR, leading to improvement in the postoperative visual field.

Craniopharyngioma in the Elderly: A Multicenter and Nationwide Study in Spain

Background: Craniopharyngioma (CP) is a rare tumor in the elderly whose clinical features and prognosis are not well known in this population. Aim: To evaluate the clinicopathological features and therapeutic outcomes of CP diagnosed in the elderly. Patients and Methods: This was a retrospective, multicenter, national study of CP patients diagnosed over the age of 65 years and surgically treated. Results: From a total of 384 adult CP patients, we selected 53 (13.8%) patients (27 women [50.9%], mean age 72.3 ± 5.1 years [range 65–83 years]) diagnosed after the age of 65 years. The most common clinical symptoms were visual field defects (71.2%) followed by headache (45.3%). The maximum tumor diameter was 2.9 ± 1.1 cm. In most patients, the tumor was suprasellar (96.2%) and mixed (solid-cystic) (58.5%). The surgical approach most commonly used was transcranial surgery (52.8%), and more than half of the patients (54.7%) underwent subtotal resection (STR). Adamantinomatous CP and papillary CP were present in 51 and 45.1%, respectively, with mixed forms in the remaining. Surgery was accompanied by an improvement in visual field defects and in headaches; however, pituitary hormonal hypofunction increased, mainly at the expense of an increase in the prevalence of diabetes insipidus (DI) (from 3.9 to 69.2%). Near-total resection (NTR) was associated with a higher prevalence of DI compared with subtotal resection (87.5 vs. 53.6%, p = 0.008). Patients were followed for 46.7 ± 40.8 months. The mortality rate was 39.6% with a median survival time of 88 (95% CI: 57–118) months. DI at last visit was associated with a lower survival. Conclusion: CP diagnosed in the elderly shows a similar distribution by sex and histologic forms than that diagnosed at younger ages. At presentation, visual field alterations and headaches are the main clinical symptoms which improve substantially with surgery. However, surgery, mainly NTR, is accompanied by worsening of pituitary function, especially DI, which seems to be a predictor of mortality in this population.

Idiopathic Intracranial Hypertension Without Papilledema With Improvement in Visual Field Defect Following Optic Nerve Sheath Fenestration: Response

Idiopathic Intracranial Hypertension Without Papilledema With Improvement in Visual Field Defect Following Optic Nerve Sheath Fenestration: Response

Changes of visual field defect in patients with acute solitary occipital lobe cerebral infarction before and after treatment

Objective To observe the changes in visual field defect before and after treatment in patients with acute solitary occipital lobe cerebral infarction. Methods From January 2017 to May 2019, 59 patients with hemianopsia who were diagnosed as acute occipital lobe cerebral infarction in Henan Provincial People's Hospital were selected. There were 35 males (59.3%) and 24 females (40.7%); aged from 50 to 72 years, with an average age of 62.86±6.10 years. There were 23 patients of right occipital cerebral infarction and 36 patients of left occipital cerebral infarction. Lesions involved 41 patients in the striated area, 8 patients involved the occipital pole, and 23 patients involved visual radiation. All patients underwent standard medical treatment. All patients underwent visual field examination before treatment, and modified rankin scale (mRS) was used to evaluate the level of visual disability after cerebral infarction. At 1, 3, and 6 months after treatment,54 patients underwent at least one visual field examination in outpatient or inpatient follow-up visits, and 5 patients were lost to follow-up; 49 patients received repeated mRS scores. The visual field defect and mRS score of patients before and after treatment were compared and analyzed. The improvement of visual field defect in the horizontal direction exceeding 10°or the vertical direction exceeding 15°was defined as improvement, otherwise it was defined as no improvement. According to the type of visual field defect, the patients were divided into two groups: complete homonymous hemianopia and incomplete homonymous hemianopia. The cumulative visual field improvement rate of the two groups of patients was calculated. An mRS score of 0 to 2 was defined as a good prognosis, and >2 was defined as a poor prognosis. Results Before treatment, of the 59 patients, 47 were complete homonymous hemianopsia and 12 were incomplete. Of the 47 patients with complete homonymous hemianopia, 26 patients had hemianopia on the right side of both eyes, 21 patients had hemianopia on the left side of both eyes; 32 patients with macular avoidance (72.3%). Among the 12 patients of incomplete homonymous hemianopia, 10 patients of quadrant blindness included 6 patients of upper quadrant and 4 patients of lower quadrant; 2 patients of partial isotropic hemianopia on one side. Of the 54 patients reviewed after treatment, the visual field improved at the last follow-up of 25 patients (46.3%), and there was no improvement in 29 patients (53.7%). The cumulative visual field improvement rate of 47 patients with complete hemianopia hemianopia before treatment was 37.2% (16/43). The cumulative visual field improvement rate of 11 patients with incomplete isotropic hemianopia before treatment was 81.8% (9/11). There was a statistically significant difference in cumulative visual field improvement between the two groups of patients (χ2 = 7.011, P<0.05). Before treatment, 59 patients had mRS scores of 1 to 2 points in 15 patients (25.4%), and 44 patients with 2 points or more (74.6%). Of the 49 patients reviewed after treatment, 28 (57.1%) had a good prognosis and 21(42.9%) had a poor prognosis. Conclusions The visual field defect of patients with homonymous hemianopsia after acute occipital infarction may be improved after treatment. The improvement mostly occurs within 1 m after treatment, and patients with incomplete homonymous hemianopsia have more significant improvements than those with complete homonymous hemianopsia. Key words: Occipital lobe; Cerebral infarction; Visual fields; Hemianopsia

Changes in Lid Crease Measurements in Levator Advancement for Ptosis.

Although previous reports addressed the differences in marginal reflex distance 1 (MRD-1) measurements based on various techniques of levator advancement, eyelid crease measurements have not been studied as markers in perioperative planning. In addition to possible benefits in optimal results for improvement of visual field defects and functional impairment, recent work has suggested that eyelid crease is important in the perception of attractiveness. Therefore, the aims of this study were to determine the change in eyelid crease measurements in levator advancement and to further expand on numerical correlation of levator advancement in preoperative planning to avoid overcorrection or undercorrection. The authors performed a retrospective analysis of preoperative and postoperative eye measurements in patients who underwent levator advancement for ptosis between August 2016 and April 2019. This study included 13 patients, all of whom had recorded preoperative and postoperative measurements of MRD-1, whereas 8 of 13 patients had additional preoperative and postoperative measurements of the mid pupil to crease and lateral limbus to crease at the level of mid pupil. All patients had increased in MRD-1, mid pupil to crease, and lateral limbus to crease measurements postoperatively. The average advancement of 4.8 mm led to an elevation of MRD-1 to 2.6 mm (n = 25) and an improvement in mid pupil to crease distance of 1.9 mm (n = 15) and lateral limbus to crease distance of 2.6 mm (n = 15). No cases of undercorrection or overcorrection were found. All patients reported satisfaction with the results, including improvement in function and quality of life. No infections, hematomas, or other complications were noted postoperatively in any of the patients. Marginal reflex distance 1 is a consistently reliable planning tool in preoperative assessment of levator advancement, with beneficial patient outcomes including improvement of visual field defects caused by ptosis and satisfaction with cosmetic results. This study is the first to report use of crease measurements (mid pupil to crease and lateral limbus to crease), which may provide additional understanding to the aesthetic value of to the levator advancement.

Neuroenhancement and neuroprotection by oral solution citicoline in non-arteritic ischemic optic neuropathy as a model of neurodegeneration: A randomized pilot study.

PurposeTo evaluate whether treatment with Citicoline in oral solution (OS-Citicoline) would increase visual function, retinal ganglion cells (RGCs) function, and neural conduction along visual pathways (neuroenhancement), and/or induce preservation of RGCs fibers’ loss (neuroprotection) in non-arteritic ischemic optic neuropathy (NAION), a human model of neurodegeneration.MethodsThirty-six patients with NAION and 20 age-matched controls were enrolled. Nineteen NAION patients received 500 mg/day of OS-Citicoline for a 6-month period followed by 3-month of wash-out (NC Group); 17 NAION patients were not treated (NN Group) from baseline to 9 months. In all subjects at baseline, and in NC and NN eyes at 6 and 9 months of follow-up, we assessed Visual Acuity (VA), Pattern Electroretinogram (PERG), Visual Evoked Potentials (VEP), retinal nerve fiber layer thickness (RNFL-T), and Humphrey 24–2 visual field mean deviation (HFA MD). Mean differences were statistically evaluated with ANOVA between Groups, and linear correlations were analysed with Pearson’s test.ResultsAt 6 months, significant differences between groups for all parameters were observed (ANOVA, p<0.01). In NC eyes, VA increased, PERG responses increased, VEP recordings improved and were significantly correlated with increases in HFA MD (p<0.01), and RNFL-T was unmodified or improved. In contrast, in NN eyes, VA, PERG, VEP responses, RNFL-T, and HFA MD were further worsened. Significant differences were still present at 9-month follow-up in the NN Group and after 3 months of OS-Citicoline wash-out in NC eyes.ConclusionsOS-Citicoline treatment induced neuroenhancement (improvement in RGCs function and neural conduction along visual pathways related to improvement of visual field defects) and neuroprotection (unmodified or improved RNFL morphological condition) in a human model of NAION involving fast RGCs degeneration.Trial registrationClinicalTrials.gov NCT03758118.

SAT-LB082 Neurosarcoidosis Presenting as Panhypopituitarism, Diabetes Insipidus and Sellar Mass

Introduction: Granulomatous hypophysitis is a rare entity with an annual incidence of 1 in 10 million. It may be primary or secondary to tuberculosis, sarcoidosis, Wegener’s disease, syphilis or mycotic infections. It accounts for <1 % of cases of panhypopituitarism or visual field defects. Isolated Neurosarcoidosis without systemic involvement is extremely rare. It can rarely present as an isolated granuloma of the sella mimicking pituitary adenoma. Case: A 47-year-old-male was admitted with generalized weakness of 1 month and headache with loss of peripheral vision of 1 week duration. MRI brain revealed a sellar mass with suprasellar extension involving the pituitary stalk and hypothalamus representing pituitary macroadenoma. Biochemical tests were evident for central hypoadrenalism, secondary hypothyroidism and hypogonadism with mild hyperprolactinemia. He had low urine specific gravity on admission and provided history of increased thirst, polyuria and nocturia from past 3 weeks. CSF analysis showed elevated CSF protein and ACE levels. Visual field testing revealed bitemporal hemianopsia. Patient underwent transsphenoidal biopsy and partial resection of pituitary mass with significant improvement in visual field defects post operatively. Pituitary biopsy showed non-necrotizing granulomatous hypophysitis. CT chest revealed hilar and mediastinal lymphadenopathy suspicious of sarcoidosis. He had positive Quantiferon and PPD testing but hilar lymph node biopsy was negative for granuloma or malignancy. CSF analysis, pituitary and lymph node biopsy were negative for bacterial, AFB and fungal culture/stain. Tests for HIV, hepatitis, syphilis, lymphoma panel and sputum AFB culture x3 were negative. He was discharged on levothyroxine, hydrocortisone, testosterone and desmopressin. He completed treatment for latent TB and was monitored as outpatient. After 8 months, his visual field defects had completely recovered. Patient was asymptomatic with unchanged hilar and mediastinal lymphadenopathy. Repeat MRI brain showed avidly enhancing thickened pituitary stalk with complete resolution of pituitary mass lesion. He was diagnosed with probable Neurosarcoidosis and referred to rheumatology. Discussion: Hypothalamic-pituitary sarcoidosis occurs in less than 10% of patients with Neurosarcoidosis. Polyuria, polydipsia and signs and symptoms of hyperprolactinemia are the most common presenting manifestations. Earlier, the endocrine dysfunction was attributed to a destructive process affecting pituitary, but pituitary responsiveness to synthetic hypothalamic releasing factors indicates that hypothalamic insufficiency is the major cause for panhypopituitarism. Diabetes Insipidus can be masked by secondary adrenal deficiency on presentation. Clinicians should be cautious of unmasking diabetes insipidus while replacing glucocorticoids in such cases. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

The rapid improvement in visual field defect observed with weekly perimetry during intensity-modulated radiotherapy for optic nerve sheath meningioma

During precision radiotherapy to treat optic nerve sheath meningioma, early improvement in visual function has been seen. This has been difficult to explain biologically. In the present study, we aimed to investigate this rapid improvement in visual function. To this end, we prospectively tested a single patient’s visual field (VF) using Humphrey automated perimetry at weekly intervals. The patient exhibited significant stepwise improvement in VF during an intensity-modulated radiotherapy course.

Neutralizing Peripheral Refraction Eliminates Refractive Scotomata in Tilted Disc Syndrome.

SIGNIFICANCEWe demonstrate that the visual field defects in patients with tilted disc syndrome can be reduced or eliminated by neutralizing the peripheral scotoma in the area of posterior retinal bowing, which may allow differentiation between a congenital anomaly and acquired pathology.PURPOSETilted disc syndrome is a congenital and unchanging condition that may present with visual field defects mimicking loss seen in neurological diseases, such as transsynaptic retrograde degeneration. Our purpose was to systematically investigate the ability of a neutralized peripheral refraction to eliminate refractive visual field defects seen in tilted disc syndrome. This was compared with the same technique performed on patients with neurological deficits.METHODSThe Humphrey Field Analyzer was used to measure sensitivities across the 30-2 test grid in 14 patients with tilted disc syndrome using four refractive corrections: habitual near correction and with an additional −1.00, −2.00 or −3.00 D negative lens added as correction lenses. Peripheral refractive errors along the horizontal meridian were determined using peripheral retinoscopy and thus allowed calculation of residual peripheral refraction with different levels of refractive correction. Visual field defects were assessed qualitatively and quantitatively using sensitivities and probability scores in both patient groups.RESULTSA smaller residual refractive error after the application of negative addition lenses correlated with improvement in visual field defects in terms of sensitivity and probability scores in patients with tilted disc syndrome. Patients with established neurological deficits (retrograde degeneration) showed improvement in sensitivities but not in probability scores.CONCLUSIONSNeutralizing the refractive error at the region of posterior retinal bowing due to tilted disc syndrome reduces the apparent visual field defect. This may be a useful and rapid test to help differentiate between tilted disc syndrome and other pathological causes of visual field defects such as neurological deficits.

Bariatric surgery and its impact on pseudotumor cerebri: A case report

PurposePseudotumor cerebri is a debilitating condition that causes severe headaches and progressive visual field loss. In this report, we present a patient with Class III obesity, with pseudotumor cerebri who failed medical management and attempted weight loss via diet and exercise. ObservationsAfter undergoing bariatric surgery, the patient had significant weight loss and improvement of visual field defects. Conclusion and importanceThese results suggest that bariatric surgery may be an effective option for patients with rapidly progressing visual loss due to pseudotumor cerebri.

The Alteration Visual Field Defect in Ischemic Stroke Patients After Three Months Therapy

Background: Ischemic stroke are lack of blood flow to the brain and it could influence the visual field. Approximately more than half of the ischemic stroke patient have visual defect.Objective : Disturbance of blood flow on visual pathway have impact to the visual field defect. In stroke ischemic patient, recirculation of penumbra at the brain on the third months after onset can rehabilitate the visual pathway, also it will improve the outcome of visual filed defect. So it could be initial detection for rehabiltation of visual field defect.Methods: This study was intended to compere visual field defect of ischemic stroke patient after three months therapy conducted form September 2014 - February 2015 in Mohammad Hoesin General Hospital Palembang. A total of 12 patients who met the inclusion criteria were recruited by consecutive sampling. All patients were endure based on ophthalmology and visual field examination using Humphrey Field Analyzer twice. First after relieving from the attack of stroke and second after three months therapy. Measurement of standard have to compare the value of MD, VFI, PSD, PD and pattern visual field defect. Results: There were significant difference in value of MD, VFI, PSD and PD&lt;0,5% for both eyes on stroke ischemic patients after three months therapy. Almost all variable value were increasing to improvement of defect. The most common type of visual field defect is homonymous hemianopia. Conclusion: There were improvement in visual field defect in patients with stroke ischemic after three months therapy.  Keywords: Ischemic stroke, visual field defect, penumbra, recirculation of brain, Mean Deviation (MD), Visual Field Index (VFI), Pattern Standard Deviasion (PSD), Pattern Deviation (PD)  Â

Correlations between the thickness of foveal ganglion cell-inner plexiform layer and visual field defect in patients of sellar region tumors with optic chiasmal compression before and after gamma knife treatment

Objective To observe the correlation between the thickness of foveal ganglion cell-inner plexiform layer (GCIPL) and visual field mean defect before and after gamma knife treatment in patients of sellar region tumors with optic chiasmal compression. Methods This was a prospective case series. 72 eyes of 37 consecutive patients suffering from optic chiasmal compression of sellar region tumors treated with gamma knife were enrolled in the study. According to the change of visual field before and after gamma knife treatment, the patients were divided into three groups. There were 13 eyes of 7 patients in group 1 with no vision defect pre- and post-treated, 34 eyes of 17 patients in group 2 with improvement of visual field defect after treatment, 25 eyes of 13 patients in groups 3 with no improvement or reorganization of visual field defect after treatment. Overall average thickness of GCIPL, and of the superotemporal, superior, superonasal, inferonasal, inferior, and inferotemporal retina were measured with the Cirrus high-definition spectral domain optical coherence tomography, and mean deviation (MD) with the Humphrey field analyzer before and 6 months after treatment. There was no significant difference in MD values between group 2 and 3 pre-treated (t=1.471, P=0.084). There was significant difference between all the groups in total average value of GCIPL thickness and the 6 quadrant GCIPL thickness values pre-treated (P<0.05). Logistic regression model was applied to analysis of the correlation between GCIPL thickness and the improvement of visual field after treatment. Results The MD values of the group 1, 2 and 3 were (-2.96 ± 0.75), (-10.24 ± 1.31), (-20.2 ± 5.88) dB at 6 months after treatment. There was significant difference between group 2 and 3 of MD value after treatment (t=6.974, P=0.000). In group 1, there was no significant difference in mean GCIPL thickness and the 6 quadrant GCIPL thickness values between pre- and post-treated(t=0.882, P=0.395). The mean thickness of GCIPL, superonasal and inferonasal GCIPL was increased than pre-treated in group 2, and the difference was statistically significant(t=2.438, 4.630, 4.457; P=0.035, 0.001, 0.001). The mean thickness of GCIPL, superonasal and inferonasal GCIPL was decreased than pre-treated in group 3, and the difference was statistically significant (t=-2.387, -4.603, -4.975; P=0.041, 0.002, 0.001). Logistic regression analysis showed that the greater of the value of average GCIPL thickness of patients with visual field defect pre-treated, the higher of the proportion of patients with improvement of visual field defect post-treated [odds ratio (OR)=2.871, P=0.000]. There was a significant correlation between the value of superonasal or inferonasal GCIPL and the improvement of the visual field post-treated (OR=5.374, 4.693; P=0.000, 0.000). There was no significant correlation between the value of superotemporal or upper or lower or inferotemporal GCIPL and the improvement of the visual field post-treated (OR=1.058, 1.101, 1.074, 1.056; P=0.183, 0.080, 0.162, 0.186). Conclusions In patients with optic chiasmal compression of sellar region tumor, the greater of the average GCIPL thickness pre-treated, the higher of the proportion of patients with improvement of visual field defect post-treated. There was a significant correlation between superonasal or inferonasal value of the GCIPL thickness and the improvement of visual field defect post-treated. Key words: Optic chiasm/ injuries; Retinal ganglion cells; Visual fields; Tomography, optical coherence

Lesion Location-Based Prediction of Visual Field Improvement after Cerebral Infarction.

BackgroundAlthough the prognosis of ischemic stroke is highly dependent on the lesion location, it has rarely been quantitatively utilized. We investigated the usefulness of regional extent of ischemic lesion (rEIL) predicting the improvement of visual field defect (VFD) in patients with posterior cerebral artery infarction.MethodsThe rEILs were measured in each individual cortex after transforming the lesions to a standard atlas. Significant improvement of VFD was tentatively defined as 20% improvement at 3 months after stroke. The performances of clinical and imaging variables predicting significant improvement were measured by support vector machine. The maximum performance of variables predicting the significant improvement was compared between subgroups of variables (clinical, baseline severity and lesion volume) and the effect of adding rEIL to those subgroups of variables was evaluated.ResultsA total of 35 patients were enrolled in this study. Left PCA infarct, MR-time from onset, rEILs in the lingual, calcarine, and cuneus cortices were good prognostic indicators of hemi-VFD (performance for predicting the significant improvement: 72.8±11.8%, 66.1±11.2%, respectively). A combination of the rEILs of each cortical subregions demonstrated a better predictive performance for hemi-VFD (83.8±9.5%) compared to a combination of clinical variables (72.8±11.8; p<0.001), baseline severity (63.0±11.9%; p<0.001), or lesion volume (62.6±12.7%; p<0.001). Adding a rEIL to other variables improved the prognostic prediction for hemi-VFD (74.4±11.6% to 91.3±7.7%; p<0.001).ConclusionsAn estimation of rEIL provides useful information regarding the ischemic lesion location. rEIL accurately predicts the significant improvement of VFD and enhances the prediction power when combined with other variables.

Transient cortical blindness after spinal surgery as initial presenting sign of hereditary thrombophilia

Sir, Cortical blindness is a rare complication of spine surgery,[1] and is followed by a period of recovery due to resolution of inflammation and edema around the lesion and to the re-activation of partially damaged perilesional tissue.[2,3] Bilateral occipital abnormalities caused by hypotension, ischemia and infarction are associated with poor prognosis. Herein, we report complete recovery of a case with cortical blindness, despite having an ischemic infarct. A 33-year-old female patient who was otherwise healthy underwent uneventful simple discectomy operation. In the immediate postoperative period, she had a syncopal attack and was hypotensive for 5-6 min. After emergency aid, she regained consciousness and complained that she could not see. On neurologic examination, both pupils were isocoric and equally reactive to light and accomodation. There was perception of hand motion. Fundoscopic examination was normal. Cranial magnetic resonance imaging (MRI) revealed hypodense areas involving the occipital lobes bilaterally [Figs. ​[Figs.1,1, ​,2a2a and ​andb].b]. D-dimer test was positive. Deep vein thrombosis in the right popliteal vein was detected ultrasonographically. In spiral computerized tomography (CT) of the thorax scan, there were patchy consolidation areas. Her electrocardiogram showed sinusal tachycardia with an incomplete right bundle-branch block. There were moderate tricuspid insufficiency and mild pulmonary hypertension echocardiographically. She was diagnosed to have massive pulmonary embolism and cortical blindness, and was admitted to the intensive care unit. Treatment was started with continuous intravenous heparin infusion. The patient's vision gradually began to improve within 24 h. Radiological cure with normal thoracal CT was seen on the seventh day. Her vision restored to its preoperative level on the 25th day. After 2 months, there were relative deficits in the right lower temporal quadrant and in the left lower hemifield in visual field examination. Contrast sensitivity evaluation showed losses at high frequencies in the right eye and at all spatial frequencies in the left eye. Color vision assessment revealed low pattern discrimination. For excluding any prothrombotic state, a haemotologic evaluation revealed heterozigousity for factor V Leiden R506Q, protrombin G20210A and MTHFRC677T. Anticoagulant therapy was initiated. In the 3rd year follow-up of the patient, near-complete regression of the infarct area was found in the MRI and improvement of visual field defects was observed [Fig. 3]. Color vision was near-perfect in both eyes. Contrast sensitivity was slightly improved. Figure 1 Diffusion-weighted image showing diffusion restriction compatible with the acute infarct involving the striate and extrastriate cortex (arrows) Figure 2 (a and b) Axial T2-weighted images showing hyperintense areas compatible with the acute infarct involving the striate and extrastriate cortex (arrows) Figure 3 Axial T2-weighted control image showing near-complete regression. There is an encephalomalasic area in the anterior part of the right occipital lobe Visual impairment in cortical blindness is highly variable, and deficits between the hemifields may be different.[4] In our patient, the infarct area was mainly in the cuneus, and corresponding visual field defects were in the lower hemifields. Besides, infarct area comprised both striate and extra-striate visual cortex initially and corresponding abnormalities in color vision and contrast sensitivity recovered with regression of the infarct area. Occipital lobe infarcts were reported to be frequently associated with a prothrombotic state, and were seen more frequently in younger patients and in patients of the female sex.[5] In young patients with cortical blindness, screening for thrombophilia should be made. Because visual loss may be reversible with initiation of immediate anticoagulation therapy, awareness, evaluation and prompt management of this rare complication is critical.

Prognostic factors of visual field improvement after trans-sphenoidal approach for pituitary macroadenomas: review of the literature and analysis by quantitative method

The objective of the study was to evaluate the preoperative visual field defect, the postoperative outcome and the possible prognostic factors in patients with pituitary macroadenoma, using a quantitative method (the mean deviation = MD), and to review the literature. A total of 73 patients, operated trough trans-sphenoidal approach, were selected, and data in single eyes were analysed by calculating the frequency and the degree of postoperative improvement (relative improvement). The visual field defect improved in 95.7% of eyes: The recovery was complete in 48.9% and partial in 46.8%. Multivariate logistic regression showed that factors, independently predictive for complete recovery, were as follows: low preoperative MD absolute value (p = 0.008), low cranio-caudal diameter of tumour (p = 0.02) and young age (p = 0.0001). The mean relative improvement in visual field defect (dMD%) was correlated with the preoperative visual acuity (p = 0.0001) and inversely related with the preoperative MD (p = 0.007) and the age (p = 0.017). The relative improvement was higher in tumours with a smaller cranio-caudal diameter (p = 0.0185). In conclusion, using a quantitative method, we can measure the degree of the postoperative visual field defect improvement. Predictive factors for a complete recovery were good preoperative visual function, young age and low cranio-caudal tumour.

Pituitary apoplexy: evaluation, management, and prognosis

To review the current standard of care in the diagnosis and treatment of pituitary apoplexy and to determine any updated clinical management strategies. Pituitary apoplexy is a rare but life-threatening medical emergency. Presenting signs and symptoms often include severe headache, visual loss, ophthalmoplegia, altered consciousness, and impaired pituitary function. Common predisposing factors include closed head trauma, blood pressure alterations, history of pituitary irradiation, cardiac surgery, anticoagulation, treatment with dopamine agonists, pituitary stimulation testing, and pregnancy. MRI imaging is the most sensitive sequence for the detection of acute and old intracranial hemorrhage. Patients often require emergent intravenous fluids, blood transfusions, and high-dose corticosteroids. Patients who remain clinically and neurologically unstable require urgent transsphenoidal surgical decompression as definitive treatment. In patients with pituitary apoplexy, improvement in visual field defects, visual acuity, and diplopia is typically observed after emergent application of therapy, often including medical and surgical treatment. Some patients may require long-term hormonal therapy after surgery.