Normal Visual Fields Research Articles

Inter-Eye Association of Visual Field Defects in Glaucoma and Its Clinical Utility.

PurposeTo investigate intereye associations of visual field (VF) defects.MethodsWe selected 24-2 VF pairs of both eyes from 63,604 patients tested on the same date with mean deviation (MD) ≥ −12 dB. VFs were decomposed into one normal and 15 defect patterns previously identified using archetypal analysis. VF pattern weighting coefficients were correlated between the worse and better eyes, as defined by MD. VF defect patterns (weighting coefficients > 10%) in the better eye were predicted from weighting coefficients of the worse eye by logistic regression models, which were evaluated by area under the receiver operating characteristic curve (AUC).ResultsIntereye correlations of archetypal VF patterns were strongest for the same defect pattern between fellow eyes. The AUCs for predicting the presence of 15 defect patterns in the better eye based on the worse eye ranged from 0.69 (superior nasal step) to 0.92 (near total loss). The AUC for predicting superior paracentral loss was 0.89. Superior paracentral loss in the better eye was positively correlated with coefficients of superior paracentral loss, central scotoma, superior altitudinal defect, nasal hemianopia, and inferior paracentral loss in the worse eye, and negatively correlated with coefficients of the normal VF, superior peripheral defect, concentric peripheral defect, and temporal wedge. The parameters are presented in the descending order of statistical significance.ConclusionsVF patterns of the worse eye are predictive of VF defects in the better eye.Translational RelevanceOur models can potentially assist clinicians to better interpret VF loss under measurement uncertainty.

Long-term Follow-up of 14 Eyes With Bilateral and Multiple Ciliary Body Cysts: Prognosis of this Rare Entity.

To describe the long-term outcomes of eyes with bilateral and multiple ciliary body cysts (CBC). This retrospective study included patients with multiple and bilateral CBC diagnosed by high-resolution ultrasound biomicroscopy and followed by a single glaucoma specialist from 2000 to 2020. All patients underwent complete ophthalmic examination including dynamic indentation gonioscopy, retinal nerve fiber layer (RNFL) measurement by optic coherence tomography and automated perimetry. Seven patients (14 eyes) with bilateral and multiple CBC were included with a mean follow-up of 98±39 months. Four eyes of 2 patients had complete angle closure at first examination and 3 of them underwent trabeculectomy with good visual outcomes. Four eyes of 2 patients had a reversible angle-closure at first examination and underwent a ultrasound biomicroscopy-guided laser peripheral iridotomy (LPI) which reopened the irido-corneal angles. Two of these eyes needed intensification of hypotensive drops during the follow-up. Among the 6 eyes (3 patients) with open angle at first examination, all had had LPI at last follow-up visit, 5 had normal RNFL and visual field and 1 received an additional hypotensive drop because of RNFL progression. Our long-term cohort of bilateral and multiple CBC demonstrates that this rare entity may have a good prognosis if LPI is performed before extension of peripheral anterior synechiae. Irreversible angle closure required trabeculectomy in 75% of cases in our cohort with however good visual outcomes.

Ocular Complications After Radiation Therapy: An Observational Study.

Aim of the StudyThe study aims to quantify the incidence of ocular complications in patients irradiated on the head and neck area in our medical center, stratified by type of neoplasm and radiation dose received.Materials and MethodsFrom an existing database of patients radio-treated in our center, we selected 25 patients irradiated in the 2011–2018 period. The patients had been treated for orbital lymphoma, nasopharyngeal carcinoma and cranial base meningioma. The selected patients received an ophthalmologic evaluation which included a complete ophthalmological and orthoptic assessment.ResultsOur results showed a significantly higher incidence of DES (dry eye syndrome) and corneal complications for eyes receiving a Dmax higher than 40 Gy, as well as for cataract incidence in eyes that had received a Dmax to the lens higher than 5 Gy. We found an overall thinning of the RNFL (retinal nerve fiber layer) in eyes that had received a Dmax higher than 50 Gy, as well as a greater MD (mean deviation) from normal visual field values.ConclusionIn conclusion, we can say that the study confirms the presence of a correlation between the received radiation dose and the onset of eye complications, despite the small sample.

Subclinical dysthyroid optic neuropathy: tritan deficiency as an early sign of dysthyroid optic neuropathy

PurposeThe aim of this research was to investigate the subclinical findings of dysthyroid optic neuropathy (DON) and to look for early indicators for optic nerve compression in patients with Graves’...

An Open-source Static Threshold Perimetry Test Using Remote Eye-tracking (Eyecatcher): Description, Validation, and Preliminary Normative Data.

PurposeTo describe, validate, and provide preliminary normative data for an open-source eye-movement perimeter (Eyecatcher).MethodsVisual field testing was performed monocularly in 64 normally sighted young adults, using (i) a Humphrey Field Analyzer (HFA) and (ii) the novel Eyecatcher procedure. Eyecatcher used a remote eye-tracker to position stimuli relative to the current point of fixation, and observers responded by looking towards the stimulus. In both tests, Goldman III stimuli were sampled from a 24-2 grid, and were presented against a 10 cd/m2 background. Participants completed each test twice to assess test–retest repeatability.ResultsMean Sensitivity (MS) did not differ between Eyecatcher and the HFA (P = 0.086), and both tests exhibited similar test–retest repeatability (CoREyecatcher = ±1.86 dB; CoRHFA = ±1.95 dB). Eyecatcher was also able to detect changes in sensitivity across the normal visual field (the “Hill of Vision”), and could differentiate the physiological blind spot from adjacent retinal locations. Mean sensitivities and 95% limits of agreement are described for each pointwise location.ConclusionsEyecatcher can use eye movements to assess visual fields in young, normally sighted adults. In such observers, it provides results similar to the current gold standard clinical device (HFA).Translational RelevanceGiven further development, eye movement perimeters such as Eyecatcher could be particularly useful for individuals unable to perform traditional perimetric assessments, such as young children or stroke patients. Full technical details and information on how to freely acquire the source code are included.

A STITCH IN TIME SAVES SIGHT: CRANIOPHARYNGIOMA

Craniopharyngiomas are rare dysontogenic, extra-axial, slow-growing tumors arising from the remnants of the Rathke’s pouch and located within the sellar or parasellar region, which can be solid, cystic, or calcified. We are reporting a case of an 11-year-old female child who presented with complaints of sudden onset rapid diminution of vision in the right eye more than the left eye for 2 months, for distant and near vision, with normal visual fields. The patient was diagnosed as having craniopharyngioma based on magnetic resonance imaging. Surgery was done without delay, restoring her vision. Histopathology of tumor confirmed the diagnosis. This case highlights the fact that immediate neuroimaging in children presenting with sudden onset, rapidly progressive vision loss helps in early diagnosis and management of craniopharyngioma and to retrieve lost vision.

Assessment of inner retina layers thickness values in eyes with pituitary tumours before visual field defects occur.

The purpose of this study was to evaluate macula, retinal nerve layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL) and macular nerve fibre layer (mNFL) thickness in patients with pituitary tumours who has normal visual field (VF). Thirty-five eyes of 35 patients with pituitary tumours with normal VF and 41 eyes of 41-healthy subjects were underwent a complete ophthalmic examination. The spectral domain- optical coherence tomography (OCT) was used to measure macular and optic disc parameters. Layer-by-layer segmentation was done automatically by using the new software. Data analyses were performed by using SPSS for Windows, version 22.0. Average of total macula thickness inner temporal (p: 0.006), outer temporal (p < 0.001), inner nasal (p: 0.03), outer nasal (<0.001) were significantly lower in pituitary tumour group than normal group. Average of RNFL (p:0.009), temporal (p: 0.001), superiotemporal (p:0.004) and inferiotemporal (p: 0.01) were significantly lower in pituitary tumour group than normal group. Average of central GCL (p: 0.01) and central NFL (p: 0.03) were significantly lower in pituitary tumour group than normal group. There was no statistically significant difference between the two groups in IPL averages. Pituitary tumour patients with normal VF had reduced nasal and temporal section of the total macula, temporal RNFL, central mGCL and mNFL thicknesses, reflecting the corresponding to the anatomical substrate of the underlying pathology of chiasmal compression. This indicates that the presence of retinal thinning may be a sign of early detection of anterior visual pathway injury before VF loss becomes apparent.

Homonymous Retinal Ganglion Cell Layer Atrophy With Asymptomatic Optic Tract Glioma in Neurofibromatosis Type I

Approximately 20% of patients with Neurofibromatosis type 1 (NF1) develop optic pathway gliomas (OPGs). Not all OPGs in NF1 necessarily become vision compromising and predicting which patients might develop visual decline is difficult at present time. Optical coherence tomography (OCT) has emerged as a useful tool able to directly assess the morphology and thickness of individual retinal layers. The ganglion cell layer (GCL) is composed of the retinal ganglion cells which receive information from photoreceptors via interneurons, while the retinal nerve fiber layer (RNFL) contains the retinal ganglion cell unmyelinated axons that merge to form the optic nerve. Lesions of the anterior visual pathway result in retrograde axonal degeneration from ganglion cell death and ultimately manifest as thinning of the RNFL and/or GCL. In this report we highlight a case of a 38 year-old woman with an NF1 associated left chiasmal and optic tract glioma who had normal visual fields and visual acuity. However, using OCT we demonstrate a homonymous pattern of GCL atrophy that corresponds with her left optic tract glioma. Given this homonymous pattern of atrophy in the GCL and the left optic tract lesion, one would expect a right homonymous hemianopia. To our knowledge this is the first reported case of a homonymous pattern of GCL-IPL atrophy in an adult with an NF1 related OPG involving the optic chiasm and optic tract, but without objective visual field or acuity deficits. This case is important because, mechanistically, it suggests that a necessary threshold of GCL atrophy may be needed before visual concerns can be detected and, secondly, it invites future studies to evaluate whether OCT may serve as a potential screening tool for those with NF1 related OPGs.

Clinical Characteristics of Pigment Dispersion Syndrome and Pigmentary Glaucoma Patients: A Cross-sectional Study

Introduction: Pigmentary Glaucoma (PG) and Pigment Dispersion Syndrome (PDS) are two different spectrums of a single disease. Since the disease is seen in younger population and is rapidly progressive blinding disease, therefore early diagnosis and treatment will reduce the burden of the disease and improve the quality of life. Aim: To evaluate clinical characteristics of PDS and PG patients in eastern part of Uttar Pradesh. Materials and Methods: This was a two years (1st January 2018 to 31st December 2019) hospital‑based retrospective cross‑sectional study of patients who attended the glaucoma clinic. Diagnosis of PDS was made when they had normal optic disc, normal visual field {with or without increased Intra Ocular Pressure (IOP)} and at least two of the following three signs were found clinically: Krukenberg spindle, homogenous moderate‑to‑heavy (≥Spaeth 2+) Trabecular Meshwork (TM) pigmentation, and any degree of zonular and/or lenticular pigment granule dusting. Patients with PDS were diagnosed with PG, if they had two or more of the following findings: initial IOP &gt;21 mmHg, glaucomatous optic nerve damage or glaucomatous visual field loss. Various parameters such as influence of demographics, IOP, Best‑Corrected Visual Acuity (BCVA), Central Corneal Thickness (CCT), Mean Deviation (MD), Visual Field Index (VFI %), spherical equivalent and clinical finding of anterior segment of study patients were analysed. Mean, standard deviation and percentage were calculated using GraphPad Instat version 3.0. Results: Among 40 patients, nine eyes of the six patients had myopia of ‑0.5D or greater, with mean refractive error of ‑3.55±4.72 spherical equivalent. The average baseline IOP in study patients (PDS+PG), was 30.21±11.42 mmHg. Twenty four (60%) patients, either in one or both eyes had glaucoma, secondary to PDS at the initial diagnosis. Thirty three (82.5%) patients had Krukenberg spindles. Homogeneous TM pigmentation was seen in all patients. Typical spoke‑like radial Iris Transillumination Defects (ITDs) were not observed in any of the patients except in one patient, who had isolated short slit‑like trans‑illumination defects in iris crypts. Conclusion: PDS patients with normal optic disc and visual field and raised IOP, should be started prophylactic treatment and needs to be monitored more closely. Thus, the finding of PDS in Indians should alert the ophthalmologist to look for glaucoma during the initial examination.

Is MRI follow-up relevant in patients with GH-secreting pituitary adenomas primarily treated and responsive to long-acting somatostatin analogues (SMSa)?

Primary SMSa treatment can be associated with hormonal control and tumor shrinkage in patients with GH-secreting pituitary adenomas. The aim of this study was to evaluate whether regular MRI follow-up was necessary in patients with acromegaly-treated and responsive to first-generation long-acting SMSa. In this retrospective monocentric study we included patients with GH/IGF-1 hypersecretion and pituitary adenomas with normal visual field, primarily treated with first-generation long-acting SMSa between 1995 and 2015 and regularly monitored (clinical evaluation, GH/IGF-1 levels and pituitary MRI) for at least 3 years. We included 83 patients (32 men and 51 women, mean age at diagnosis 50 ± 12 years) with mean GH = 19.3 ± 25.6 ng/mL, IGF-1 = 284 ± 110% ULN and pituitary adenoma height = 12.9 ± 4.7 mm. Mean follow-up was 8.9 ± 4.9 years in 36 controlled patients and 2.0 ± 1.6 years in 47 partial responders to SMSa alone. No significant increase in pituitary adenoma height was observed. Pituitary adenoma height decreased significantly in controlled patients (diagnosis: 11.9 ± 4.8 mm, SMSa: 9.6 ± 3.3 mm, P < 0.001), and in partially responders (diagnosis: 13.6 ± 4.5 mm, SMSa: 11.5 ± 4.5 mm, P < 0.001). During SMSa treatment, no significant increase in GH-secreting adenoma size was observed. Primary SMSa treatment was associated with a significantly decrease in adenoma height in our population. Our cohort data suggest that regular MRI follow-up does not seem relevant in patients with acromegaly who are responsive to SMSa treatment.

Clinical validation trial of Glaucoma Easy Screener (GES) as a low‐cost and portable visual field screening tool

AbstractPurposeThe aim of this study is to compare the performance of Glaucoma Easy Screener (GES), as a low cost and portable visual field screening tool to the glaucoma screening test (GST) from Octopus.MethodsGES is comprised of a Moto G5 smartphone, Homido v1 virtual reality headset and a gaming joystick for user input. The screening app’s design is based on the recently introduced Octopus GST perimeter. The test contains 28 points in the central 300. Test stimuli at each location are presented at an intensity level that can be detected in 95% of the time in case of a normal visual field. The app monitors false positive errors with catch trials and fixation losses using the blind spot method. Test result is presented with a plot of seen and missed points along with other parameters including test duration and reliability indices. A normative database for the GES was constructed by testing 62 eyes of 33 normal subjects (aged 22–56, 10 male/23 female) using a threshold procedure. To evaluate agreement between Octopus GST and GES, 36 eyes of 18 subjects (among the 33 normal subjects) were tested both with GES and Octopus GST.ResultsThere is a good level of agreement between Octopus GST and GES, with 31 eyes(86%) showing above 85% agreement, based on the count of seen and missed points. There was above 85% agreement for 24 points in all eyes. The remaining 4 points had an agreement between 78 and 85%. Test duration was slightly higher for GES with an average of 2 min per eye compared to 1.1 min with Octopus GST.ConclusionsResults from this clinical trial show a good level of agreement between GES and Octopus GST. GES can serve as a low‐cost and portable visual field screening kit to complement other glaucoma tests, to make referral decisions in situations where standard equipment is not available.

A Comparison of OCT Parameters in Identifying Glaucoma Damage in Eyes Suspected of Having Glaucoma

To compare retinal nerve fiber layer thickness (RNFLT) and Bruch's membrane opening minimum rim width (BMO-MRW) measured by spectral domain optical coherence tomography (SDOCT) for diagnosing glaucoma in those suspected of having the disease. Observational cohort study. 113 eyes from 81 patients suspected of having glaucoma based on optic nerve appearance. Participants were imaged using SDOCT and RNFLT and BMO-MRW were measured. All participants had normal visual fields at the time of imaging, but were considered suspects based on the appearance of the optic disc during clinical examination. Eyes were classified as glaucomatous or non-glaucomatous based on documented stereophotographic evidence of progressive glaucomatous change in the appearance of the optic nerve or retinal nerve fiber layer occurring before the imaging session. For each parameter, we calculated the area under the receiver operating characteristic (ROC) curve and the sensitivity with fixed specificities of 80% and 95%. Areas under the ROC curves. Of the 113 eyes suspected of having glaucoma, 52 (46.0%) eyes had progressive glaucomatous optic nerve changes and were classified as having pre-perimetric glaucoma and 61 (54.0%) eyes did not have progressive glaucomatous optic nerve changes (followed untreated for an average of 9.4±3.2 years) and were classified as normal. The areas under the ROC curves were 0.89 (95% CI: 0.84-0.95) for global RNFLT and 0.75 (95% CI: 0.65-0.85) for global BMO-MRW (p=0.006). The sensitivity at 95% specificity was 60% for the global RNFLT parameter and 40% for the global BMO-MRW parameter. The RNFLT parameters that achieved areas under ROC curve ≥0.80 were global (0.89), supero-temporal (0.80), infero-temporal (0.87), and supero-nasal (0.81). The only BMOBRW parameter that achieved area under ROC curve ≥0.80 was infero-temporal (0.82). Our findings suggest that RNFLT parameters may be better able to identify pre-perimetric glaucomatous damage in glaucoma suspects than BMO-MRW.

Differential Effects of Aging in the Macular Retinal Layers, Neuroretinal Rim, and Peripapillary Retinal Nerve Fiber Layer

We determined the differential aging effects of the inner 6 layers of the macula in contrast to the minimum neuroretinal rim width (MRW) and peripapillary retinal nerve fiber layer (RNFL) thickness. Cross-sectional, multicenter study. An approximately equal number of white subjects with a normal ocular and visual field examination in each decade group from 20 to 90 years. OCT of the macula, optic nerve head, and peripapillary retina. Sectoral measurements of the inner 6 layers of the macula; age-related decline of each of these layers; strength of the associations with age of the macular parameters, MRW, and peripapillary RNFL thickness; and association between ganglion cell layer (GCL) thickness and MRW and peripapillary RNFL thickness. The study sample comprised 1 eye of 246 subjects with a median (range) age of 52.9 (19.8-87.3) years. Of the 6 layers, there was a statistically significant decline with age of only the GCL, inner plexiform layer, and inner nuclear layer thickness with rates of-0.11 μm/year,-0.07 μm/year, and-0.03 μm/year, respectively. These rates corresponded to 2.82%, 2.10%, and 0.78% loss per decade, respectively, and were generally uniform across sectors. The rate of loss of MRW and peripapillary RNFL thickness was-1.22 μm/year and-0.20 μm/year, corresponding to 3.75% and 2.03% loss per decade. However, the association of GCL thickness change with age (R2 = 0.28) was approximately twice that of MRW and RNFL thickness (R2 = 0.14 for each). In concordance with histopathologic studies showing age-related loss of retinal ganglion cell axons, we showed a significant decline in GCL thickness, as well as MRW and peripapillary RNFL thickness. The stronger relationship between aging and GCL thickness compared with the rim or peripapillary RNFL may indicate that GCL thickness could be better suited to measure progression of structural glaucomatous loss.

Repeat Visual Field Assessments for Patients with Normal Visual Field Tests at their Referring Optometric Practice

Data on visual fields of 501 consecutive patients, 1002 eyes/visual field assessments were collected. The positive predictive value of a normal visual field at the patients referring optometrist was 97% for the right eye and 98% for the left eye. From all the visual field assessments the rate of a visual field where the glaucoma hemifield test (GHT) was outside normal limits (ONL) was 16% for the right eye and 7% for the left eye. There was very little observed association between the referral diagnosis, the IOP at referral, age of patient or the sex of the patient on the likelihood of having an abnormal visual field.

Accuracy of machine learning for differentiation between optic neuropathies and pseudopapilledema

BackgroundThis study is to evaluate the accuracy of machine learning for differentiation between optic neuropathies, pseudopapilledema (PPE) and normals.MethodsTwo hundred and ninety-five images of optic neuropathies, 295 images of PPE, and 779 control images were used. Pseudopapilledema was defined as follows: cases with elevated optic nerve head and blurred disc margin, with normal visual acuity (> 0.8 Snellen visual acuity), visual field, color vision, and pupillary reflex. The optic neuropathy group included cases of ischemic optic neuropathy (177), optic neuritis (48), diabetic optic neuropathy (17), papilledema (22), and retinal disorders (31). We compared four machine learning classifiers (our model, GoogleNet Inception v3, 19-layer Very Deep Convolution Network from Visual Geometry group (VGG), and 50-layer Deep Residual Learning (ResNet)). Accuracy and area under receiver operating characteristic curve (AUROC) were analyzed.ResultsThe accuracy of machine learning classifiers ranged from 95.89 to 98.63% (our model: 95.89%, Inception V3: 96.45%, ResNet: 98.63%, and VGG: 96.80%). A high AUROC score was noted in both ResNet and VGG (0.999).ConclusionsMachine learning techniques can be combined with fundus photography as an effective approach to distinguish between PPE and elevated optic disc associated with optic neuropathies.

Patterns of retrograde axonal degeneration in the visual system.

Conclusive evidence for existence of acquired retrograde axonal degeneration that is truly trans-synaptic (RTD) has not yet been provided for the human visual system. Convincing data rely on experimental data of lesions to the posterior visual pathways. This study aimed to overcome the limitations of previous human studies, namely pathology to the anterior visual pathways and neurodegenerative co-morbidity. In this prospective, longitudinal cohort retinal optical coherence tomography scans were acquired before and after elective partial temporal lobe resection in 25 patients for intractable epilepsy. Newly developed region of interest-specific, retinotopic areas substantially improved on conventional reported early treatment diabetic retinopathy study (ETDRS) grid-based optical coherence tomography data. Significant inner retinal layer atrophy separated patients with normal visual fields from those who developed a visual field defect. Acquired RTD affected the retinal nerve fibre layer, ganglion cell and inner plexiform layer and stopped at the level of the inner nuclear layer. There were significant correlations between the resected brain tissue volume and the ganglion cell layer region of interest (R = -0.78, P < 0.0001) and ganglion cell inner plexiform layer region of interest (R = -0.65, P = 0.0007). In one patient, damage to the anterior visual pathway resulted in occurrence of microcystic macular oedema as recognized from experimental data. In the remaining 24 patients with true RTD, atrophy rates in the first 3 months were strongly correlated with time from surgery for the ganglion cell layer region of interest (R = -0.74, P < 0.0001) and the ganglion cell inner plexiform layer region of interest (R = -0.51, P < 0.0001). The different time course of atrophy rates observed relate to brain tissue volume resection and suggest that three distinct patterns of retrograde axonal degeneration exist: (i) direct retrograde axonal degeneration; (ii) rapid and self-terminating RTD; and (iii) prolonged RTD representing a 'penumbra', which slowly succumbs to molecularly governed spatial cellular stoichiometric relationships. We speculate that the latter could be a promising target for neuroprotection.

A new look at perimetry

Visual field assessment, or perimetry, poses a surprisingly rich set of interesting problems. Current standards of care include Zeiss’s Humphrey Visual Field Analyzer (HVFA) and Haag-Streit’s Octopus. These de facto standards allow comparison across time and between examinees, but they are labor-intensive to use, bulky, and expensive. In addition, the tests are not optimally designed from a psychophysical point of view. We describe psychophysical improvements in a new, head-mounted VR displays for perimetry. To disambiguate false alarms we use an nAFC task rather than a go/no go button press; to improve fixation we do not require suppression of the orienting reflex, and use a high acuity task at fixation rather than instructions to fixate; we use binocular viewing because monocular patching increases the gain on neural noise from the occluded eye; we use blurred decrement stimuli rather than small increment stimuli, and target sizes and contrasts that equate visibility across the normal visual field. The new test has surprising spatial precision in normally sighted individuals, and visual field maps in patients with disease look similar to traditional test results. Portability, low cost, low discomfort, and ease of use make it feasible for patients to test themselves frequently at home. Disclosure: the author is an employee of Vivid Vision, Inc., which is developing the new test as a commercial product.

Visual Vignette

Case Presentation: A 25-year-old woman presented with galactorrhea to the endocrinology clinic. She had regular menstrual cycles until she began depot medroxyprogesterone a few years prior. She denied headaches or visual changes. She had no significant past medical or surgical history. On exam, she had a normal visual field on confrontation test. She did not have appreciably delayed reflexes or dry skin. Lab evaluations revealed a prolactin of 69 ng/mL (normal, 3.0 to 30.0 ng/mL). Prolactin dilution ruled out a hook effect. Other hormones levels were: TSH >150 mIU/L (normal, 0.40 to 4.50 mIU/L), free T4 0.4 ng/dL (normal, 0.8 to 1.8 ng/dL), and AM cortisol 13.4 mcg/dL (normal, 4.0 to 22 mcg/dL). Thyroid peroxidase antibody was 394 IU/mL (normal, <9 IU/mL) and thyroglobulin antibody was 2 IU/mL (normal, ≤1 IU/mL). LH was <0.2 mIU/mL (normal in midfolicular phase, 2.12 to 10.89 mIU/mL) and FSH was 4.6 mIU/mL (normal in midfollicular phase, 3.85 to 8.78 mIU/mL). Visual field testing revealed mild field cut bilaterally. Magnetic resonance imaging (MRI) of the brain revealed a 2 × 1.5 × 1 cm pituitary mass impinging on the optic chiasm (Fig. 1). The patient was initiated on levothyroxine which resulted in resolution of galactorrhea and hyperprolactinemia. It also led to a significant reduction of the size of the pituitary mass (Fig. 2) and resolution of the visual field defect within one year. What is the diagnosis? Fig. 2 View Large Image Figure Viewer

Cystic appearance - a new feature of solid fibrous tumours in the lacrimal gland: a case report with literature review

BackgroundSolitary fibrous tumours (SFTs) rarely occur in the orbit, especially in the lacrimal area. These tumours are mostly solid. Cystic changes have been documented, but they remain very rare. Only three cases of primary orbital solitary fibrous tumours with cystic changes have been reported in the literature, but no cases have been reported to occur in the lacrimal gland. Solitary fibrous tumours generally follow a benign course and are treated definitively with surgical excision. Data from the literature suggest that the cystic nature of SFT presents a risk of recurrence and could be a harbinger of malignancy.Case presentationA 42-year-old woman was admitted to the endocrinology department for right unilateral exophthalmia and epiphora in the last 8 months. An ophthalmological evaluation showed exophthalmia only in the right eye (22 mm) and normal visual acuity, visual field and extraocular movements. Investigations revealed normal thyroid function. Orbital magnetic resonance imaging detected a 4 × 2,2 × 2,7 cm septate pseudocystic mass in the right lacrimal gland. Given her lacrimal gland tumour diagnosis, the patient was submitted for neurosurgical intervention with total ablation of the tumoural mass and complete right dacryoadenectomy. Although the intraoperative extemporaneous examination results were suggestive of a haemangiopericytoma, histological and immunocytochemical examination showed an extrapleural SFT. The postoperative clinical evolution was favourable, with remission of the exophthalmia. Fifteen months after surgery, no signs of recurrence were noticed.ConclusionsWe report the first case of an SFT with cystic changes in the lacrimal gland. Although the presence of cavitary lesions alone does not necessarily indicate aggressive behaviour, cystic changes pose a risk of recurrence and may suggest malignant transformation over time. As a result, our case requires long-term follow-up due to recurrence and malignant potential.

Evaluation of visual field defects in neuro- ophthalmology

Aim: The aim of the study is to evaluate the visual field defects in neuro-ophththamology and in patients with lesions involving the visual pathway. Introduction: Visual field testing is done with Standard automated perimetry. This helps in the early diagnosis of visual field defects in brain tumours, localization, differential diagnosis, monitoring progression and recurrences and helps in diagnosing hidden visual loss. Materials and Methods: 100 cases were included in the study. These cases had intracranial tumours, pituitary tumours and pailloedema. All the cases were referred for visual fields examination from neurology and neurosurgery departments. Standard automated perimetry was done in all cases. Results: Out of 100 cases, 31 cases had pituitary tumours, 33 patients had papilloedema and 36 patients had other intracranial tumours. Normal visual fields were noted in 36 cases and visual field defects were noted in 64 cases. Bitemporal hemianopia was noted in 18 cases, homonymous hemianopia in 16 cases, enlargement of blind spot in 15 cases, generalized constriction of fields in 5 cases, quadrantinopia in 6 cases and field defects involving three quadrants was noted in 4 cases. Conclusion: Complete Ophthalmological examination including perimetry should be done in patients with intracranial tumors involving visual pathway. Some patients are visually asymptomatic even when they have visual field defects. Automated perimetry is the most sensitive and specific for diagnosing the visual field defects in neuro-ophthalmology cases. Perimetry is useful in localizing the tumors and should be repeated after surgery to monitor for resolution or recurrence. Patients with visual field defects have difficulty in doing their daily activities and affect the quality of life. Rehabilitation should be considered in these cases. Keywords: Bitemporal hemianopia, Homonymous hemianopia, Papilloedema, Pituitary tumors, Visual field defects.