Preoperative Visual Status Research Articles

Early Visual Outcome of Surgically Treated Anterior and Middle Skull Base Meningiomas: A Prospective Multicenter Observational Study

Background: Meningiomas are the most common primary intracranial tumors. Visual deterioration is the first symptom for most patients with anterior and middle fossa meningiomas. The main aim of surgery is the total removal of the tumor, resulting in improvement or preservation of preoperative visual status. Objective: To assess a 30-day visual outcome after surgical treatment of anterior and middle skull base Meningiomas. Methods: Institution-based prospective cross-sectional study was conducted among hospitalized and operated patients from September 1, 2020, to August 31, 2020. Early postoperative visual outcome and associated factors affecting visual outcome were determined using the WHO visual criteria. Bivariate and multivariate correlation analysis was performed to identify associated variables. The p-value of <0.05 was considered significant. Results: Among the 43 patients enrolled, the majority 40(93%) were females and 27(62.8%) of the patients were under the age of 45. The commonest presenting symptoms were headache and visual impairment in 41(95.3%) and 33(78.7%) of patients respectively. Postoperative visual improvement was found in 21(48.8%) of patients whereas 18(41.9%) of patients had a similar course and 4(9%) of the patients deteriorated. Age, duration of visual deterioration, peri-operative visual status, tumor size, optic canal extension, and Simpson grading of resection were found to have a significant association with visual outcome. Conclusion: Postoperative visual improvement was found in 21(48.8%) of patients, which is comparable with most studies. The postoperative visual outcome is favorably affected by a shorter duration of visual deterioration before surgery, better preoperative visual status, and tumor size less than 4cm.

Reliability of intraoperative visual evoked potentials (iVEPs) in monitoring visual function during endoscopic transsphenoidal surgery

ObjectiveTo refine a reliable and reproducible intraoperative visual evoked potentials (iVEPs) monitoring protocol during endoscopic transsphenoidal surgery. To assess the reliability of baseline iVEPs in predicting preoperative visual status and perioperative iVEP variation in predicting postoperative visual outcome.MethodsSixty-four patients harboring tumors of the pituitary region were included. All patients underwent endoscopic endonasal approach (EEA) with iVEPs monitoring, using a totally intravenous anesthetic protocol. Ophthalmological evaluation included visual acuity and visual field studies.ResultsPreoperatively, visual acuity was reduced in 86% and visual field in 76.5% of cases. Baseline iVEPs amplitude was significantly correlated with preoperative visual acuity and visual field (p = 0.001 and p = 0.0004, respectively), confirming the reliability of the neurophysiological/anesthetic protocol implemented.Importantly, perioperatively the variation in iVEPs amplitude was significantly correlated with the changes in visual acuity (p < 0.0001) and visual field (p = 0.0013). ROC analysis confirmed that iVEPs are an accurate predictor of perioperiative visual acuity improvement, with a 100% positive predictive value in patients with preoperative vision loss.ConclusionsiVEPs during EEA is highly reliable in describing preoperative visual function and can accurately predict postoperative vision improvement.SignificanceiVEPs represent a promising resource for carrying out a more effective and safe endoscopic transsphenoidal surgery.

Visual Outcome Predictors After Surgical Excision Of Meningiomas Compressing The Optochiasmatic Complex

Abstract Background Meningioma arising from locations in the vicinity of optic nerve or chiasm may affect the visual function which sometimes the presentation of such tumors. Decompression of the optic nerve or chiasm can give a chance to the visual function to recover. Methods 30 patients who had visual function affection and underwent meningioma excision are followed up for a period of one year with regular follow of their visual function periodically. Results In this study, females were more prevalent than males, 24 out of 30, age ranged from 24 to 72 years at the time of surgery, half the patients (15) presented with visual deterioration, the other patients presented with headache, seizure, proptosis or accidentally discovered. 22 patients improved concerning their visual function over time, 6 patients had stationary course and 2 patients deteriorated postoperatively. Conclusion Follow up of patients after surgical excision of meningioma compressing the anterior optic pathway showed gradual improvement in vision in follow up period up to one year, although the improvement in visual function showed a surge in early postoperative period, with continuous less steep improvement afterwards till the end of the observation period. Surgical excision of meningiomas compressing the anterior visual pathway give chance for recovery of visual function, more in younger patients, patients with shorter period of visual deterioration, patients with mild affection of the preoperative visual status. No statistically significant influence of tumor site, size, degree of excision and surgical approach on the postoperative visual outcome in this series.

Predictive Factors for Postoperative Visual Recovery in Surgically Treated Suprasellar Meningioma: A Retrospective Analysis

Abstract Background: Post-operative visual outcome in surgically treated suprasellar meningiomas is a great concern for surgeon, patient and of course for the health system. Certain reports were published before questioning about the aim of treating such tumors in which visual recovery cannot be guaranteed. It is important to classify the possible factors that may predict the prognosis thereafter. Aim of Study: Assessment of the visual function periop-eratively and to delineate the factors of visual recovery in surgically treated suprasellar meningioma. Patients and Methods: This was a retrospective analysis of 24 patients who were operated for suprasellar meningioma in Kasr Al-Ainy University Hospital from January 2018 to July 2020. The following predictive factors were tested: Age, duration of symptoms, pre-operative visual function damage, and radiological criteria of the tumor. Results: An overall improvement in visual function was seen in 14/24 patients (58.3%) in our study. The mean and standard deviation of symptoms' duration in months were 12.36±5.11 (3-23 months). Gross total resection was achieved in 19 cases (79.1%). Gross total resection achieved improve-ment of overall visual function in 73.7% of cases with statis-tically significant difference versus subtotal resection (p-value =0.03). It has been found that duration of symptoms (less than 12 months), mild pre-operative visual symptoms, tumor size less than 3cm, absence of optic nerve extension and gross total resection are related to post-operative improvement in visual outcome. Conclusion: Visual recovery of surgically treated supra-sellar meningiomas is greatly dependent on duration of symp-toms, pre-operative visual status, tumor size, adherence to strategic neurovascular structures and gross total resection.

Improvement of Vision after Resection of Pituitary Tumor

Background: Pituitary adenomas are the most common type of pituitary disor­der. Compression of anterior visual apparatus leads to impairment of vision. Visual impairment depends on individual relation between tumor and visual apparatus, duration of compression, timing of operative intervention amongst others. Surgical excision is treatment of choice for tumors causing impairment of vision. Predicting outcome after surgical decompression thus helps both patient and surgeon to make realistic expectations and avoid unnecessary complication from overzealous aggressiveness. Predictors of visual outcome are not well established. This study aims to identify factors that predict visual improvement after resection of pituitary tumor.&#x0D; Methods: A prospective study was planned to study factors associated with visual outcome. Visual acuity was measured by using snellen’s chart and categorized using WHO vision impairment scale for distant vision. Visual field was measured either by Humphrey or Goldmann perimetry. Visual evaluation was done before surgery and after 3 months of surgery. Data was analyzed using SPSS version 23.&#x0D; Results: Twenty-eight eyes of fourteen patients were evaluated. Mean age at presentation was 38 years. Mean duration of impairment of vision at presentation was 13 months. Nonfunctioning pituitary adenoma was the most common pathology. Mean size of tumor was 3.07 cm. Visual acuity improvement was seen in 17(61%) and visual field improvement in 16(57%) of patients. Visual outcome was significantly affected by preoperative visual status and size of tumor. Extent of resection, duration of symptom were not associated with visual outcome.&#x0D; Conclusion: Excision of Pituitary tumor from sella provides enough decompression to anterior visual apparatus resulting in improvement of visual acuity and field of vision. Preoperative visual status and size of tumor can predict postoperative visual outcome.

Factors related to survival outcomes following orbital exenteration: a retrospective, comparative, case series

BackgroundOrbital exenteration is a disfiguring procedure that aims to achieve local control. It is commonly a part of the management of malignant orbital tumor which is a life-threatening condition. It is necessary to determine predictive factors associated with overall survival (OS) following orbital exenteration.MethodsThis was a retrospective, comparative, case series of 39 patients with malignant tumors who underwent orbital exenteration. Patient records were reviewed for age, clinical presentation, preoperative visual acuity (VA), tumor size, surgical margin, tumor invasiveness, recurrent disease, and status of distant metastasis. Kaplan-Meier curves were used to assess OS and event-free survival (EFS). The predictive factors related to OS were identified using multivariate analysis.ResultsThe mean age was 62.9 years (range, 5.5 to 89.7 years), 68.4% presented with VA < 20/400. The mean size of all tumors was 32 ± 18 mm. Distant metastasis at diagnosis was reported in 11 patients (28.2%). Twenty-two patients died during follow-up. The median OS and EFS were 3.89 years and 3.01 years, respectively. The predictive factors for worse OS on multivariate analysis were preoperative VA < 20/400 (adjusted hazard ratio [aHR] 4.67, P = 0.003), tumor size larger than 20 mm (aHR 3.14, P = 0.022,) and positive distant metastasis at diagnosis (aHR 15.31, P < 0.001).ConclusionsThe prognostic factors for poor survival outcome following orbital exenteration were a preoperative VA < 20/400, tumor size > 20 mm, and distant metastasis at diagnosis mostly due to patient negligence.

Stratification of predictive factors to assess resectability and surgical outcome in clinoidal meningioma

ObjectiveMeningiomas of the clinoidal region pose significant surgical challenges due to their close proximity and intimate relation with surrounding critical neurovascular structures. Our aim was to describe our institution’s experience with the management of clinoidal meningiomas, identify predictive factors and develop a comprehensive grading system to assess the extent of resection. MethodsThe medical records of 36 consecutive patients underwent surgery from 1995 to 2015 with clinoidal meningiomas were retrospectively reviewed. Using selected clinical features and tumor characteristics, a grading scale was devised and utilized to assess a degree of tumor resectability. The factors included: preoperative visual status(no visual loss=0, visual loss=1), tumor volume: small (<13.5cm3=1), moderate (13.5–30cm3=2), and large (>30cm3=3),relationship with the internal carotid artery (no displacement=0, displacement=1, encasement=2, stenosis=3 and bilateral involvement=4) tumor extension into the cavernous sinus (yes=1, no=0) and invasion into the optic canal (yes=1, no=0), (defined as tumor beyond the falciform ligament). A grading system was designed using the total scores (10) in this classification and separating patients into two groups: group 1 with scores of 5 or less, group 2 with scores more than 5. ResultsThe patients mean age at the time of intervention was 61 years. The tumor involved the cavernous sinus in 38.9% of patients and invaded the optic canal in 36% of cases. The patient presented with visual impairment in 89% of cases. Vision improved in 28% and remained stable in 63% of cases. The mean volume of a tumor was 16.99cm3. The most common approach involved pterional with or without anterior clinoidectomy. After stratification, group 1 consisting of 22 patients and in group 2, 14 patients. Gross total resection (Simpson Grade I or II) was achieved in 75% of surgeries and subtotal and partial resections were achieved in 25% of cases. Group 1 patients had higher gross total resection rate than group 2 (p=0.009). Only optic canal involvement was significantly associated with the extent of resectabilty in a univariate analysis (p=0.03). Four patients developed tumor recurrence with median recurrence duration of 89 months (53–204 months). Three patients underwent GKRS and one patient underwent repeat surgery at the time of recurrence. ConclusionsA grading system can be employed in patients who present with clinoidal meningiomas and serve as an aid in planning an appropriate treatment strategy and establishing the prognosis. Radical resection can be planned in patients with favorable tumor criteria (groups 1) while a less aggressive surgical approach followed by stereotactic radiosurgery may be better suited for patients with less favorable tumor characteristics (group 2).

Epidemiological study of patients availing free cataract services of national programme of control of blindness

Purpose: To find the proportion of patients who are blind or have low vision prior to undergoing free cataract surgery at a tertiary referral center, selected from free eye camps. To evaluate which patient groups are more in need of free cataract surgery, a series of consecutive cases of cataract that attended free eye camps and were operated during three years, 2008-2010, were evaluated. Materials and Methods: Using computerized assessment systems, we congregated data on pre-operative visual status, diagnosis, condition of other eye, age, gender, caste, and locality for 2507 patients. Visual status was defined as per World Health Organisation (WHO) classification. Results: A total of 2507 (15.06%) operations were performed out of 16,637 cases who attended eye camps, 63.3% were blind (V.A.<3/60) patients, 19.2% were with low vision (V.A. <6/60). Five hundred and seventy-eight (23.1%) patients were between 60-64 years of age followed by 491 (19.6%) in 70-74 years of age, and 456 (18.2%) in 65-69 years of age group. About 74.9% operations were performed on patients above 60 years of age. Females outnumbered males in ratio 1.3: 1.0 and operated cases of backward caste were 86.59% in comparison to general population (13.4%). Conclusion: The demand for free surgery amongst blind patients is still high for underprivileged urban as well as rural population. Backward caste, females, and citizens of age groups 71-80 and 81-90 are most in need of services of cataract programs because of lack of awareness and affordability.

Early Post-operative Visual Outcome in Patient with Pituitary Adenoma

Background: Pituitary adenoma, which accounts for 17.4% of all brain tumors, is the third most frequently diagnosed brain tumor, following intracranial glioma and meningioma. The visual disturbance in pituitary adenoma ranged from blurring of vision with or without headache to total loss of vision. In patients with visual field defects, bitemporal hemianopia was the commonest visual field defect. Early improvement of visual function is one of the major indication surgery. Objective: The purpose of this study was to comparison between the pre and post-operative visual parameters and to find out the value in assessment of the prognosis of early postoperative visual function and also to find out the factor which influence the early post-operative visual outcome. Methods: A prospective study was done from September 2010 to April 2012 in the department of neurosurgery, Bangabandhu Sheikh Mujib Medical University, 30 cases of pituitary adenoma had been included in this study of those who were presented with visual symptoms. Visual assessment was done before the operation and outcome was analyzed at discharged from hospital. Results: Within 60 eyes, 13 (43.3%) patients presented with blindness of one or both eyes. 10 (33.3%) presented with uniocular and 3 (10.0%) presented with binocular blindness. Duration of the symptoms ranged from 2 months to 48 months. Patients underwent either transcranial or transsphenoidal tumor decompression. At discharge out of 30 patients, 23 (76.7%) showed improvement, 2 (6.6%) patients were deteriorated post-operatively. P value was &lt;0.001, in z ‘test’, Z=91.5, which was highly significant. Post-operative visual status was analyzed with age, sex, duration of symptoms, suprasellar extension, and methods of surgery and extent of tumor resection to find out that any other factor influenced the visual outcome. In bivariate analysis it was shown that only duration of the symptoms only other factor that influenced the visual outcome (statistically significant, p value 0.017). Conclusion: With this study it was statistically proved that pre-operative visual status is the main factor for improvement of early post-operative visual outcome in pituitary adenoma and duration of symptoms had also influence the early post-operative visual outcome. Duration less than 12 months had a favorable outcome. DOI: http://dx.doi.org/10.3329/bjn.v28i2.17182 Bangladesh Journal of Neuroscience 2012; Vol. 28 (2): 108-115

Ophthalmological outcome after resection of tumors based on the pineal gland

Descriptions of visual dysfunction in pineal gland tumors tend to focus on upward gaze palsy alone. The authors aimed to characterize the nature, incidence, and functional significance of ophthalmological dysfunction after resection of tumors based on the pineal gland. Review of a retrospective case series was performed and included consecutive patients who underwent surgery performed by a consultant neurosurgeon between 2002 and 2011. Only tumors specifically based on the pineal gland were included; tumors encroaching on the pineal gland from other regions were excluded. All patients with visual signs and/or symptoms were reviewed by a specialist consultant neuroophthalmologist to accurately characterize the nature of their deficits. Visual disturbance was defined as visual symptoms caused by a disturbance of ocular motility. A total of 20 patients underwent resection of pineal gland tumors. Complete resection was obtained in 85%, and there were no perioperative deaths. Visual disturbance was present in 35% at presentation; of those who had normal ocular motility preoperatively 82% had normal motility postoperatively. In total, 55% of patients had residual visual disturbance postoperatively. Although upward gaze tended to improve, significant functional deficits remained, particularly with regard to complex convergence and accommodation dysfunction. Prisms were used in 25% but were only ever partially effective. Visual outcome was only related to preoperative visual status and tumor volume (multivariate analysis). Long-term visual morbidity after pineal gland tumor resection is common and leads to significant functional impairment. Improvement in deficits rarely occurs spontaneously, and prisms only have limited effectiveness, probably due to the dynamic nature of supranuclear ocular movement coordination.

Evaluation of Post-Operative Visual Outcomes of Cataract Surgery in Ghana

Purpose : To evaluate post-operative visual outcomes after cataract surgeries performed at 2 tertiary referral hospitals in Ghana Methods : A retrospective consecutive case review of hospital –elective-cataract surgeries of all ages performed at two tertiary referral centers in Southern Ghana during a 3-year-period was carried out. Data was compiled on demographic characteristics, pre- and postoperative visual acuities and surgical complications. The preoperative and postoperative visual status was classified using the World Health Organization (WHO) category of Visual Impairment and Blindness. The standard parameters of assessing outcome of cataract surgery and the WHO criteria for grading the outcome of cataract surgery were used. Results : A total of 1288 unilateral cataract extractions were performed within the 3-year-period of this review. Mean age of the patients at operation was 64.47 ± 16.7years. Small incision cataract surgery (SICS) with intraocular lens implant (83.8%) was the major surgical technique. One thousand two hundred and eighty four eyes (99.7%) were blind (VA <3/60) before surgery of which fewer than 9.5% remained blind postoperatively. The proportion of post operative eyes with good outcome (6/6-6/18) was 22.0% within 48 hours of surgery and 41.2% at 4-6 weeks follow up. Outcome was poor (<6/60) in 29.2% within 48 hours of surgery and 9.5% at 4-6 weeks follow up. Nearly half of the operative eyes had borderline outcome (6/24-6/60) within 48 hours of surgery and at follow up. ECCE +IOL operating technique achieved the best results, resulting in 54.6% of the operated eyes achieving good outcome. Only 2.8% of the operated eyes had surgical complications at follow up, of which posterior capsular opacities (50%) and vitreous loss (13.3%) were the major causes. A total of 1164 (90.4%) of the operated eyes did not have optical correction after surgery. Conclusion : Over 41.2% of post-operative eyes patients in this study had very good visual outcome following cataract surgery in the study population. Nevertheless, greater attention to post-operative care and uncorrected refractive error is needed. Keywords : Cataract surgery, cataract surgical outcome, visual outcome.

Meningiomas involving the optic canal: pattern of involvement and implications for surgical technique

Juxtasellar meningiomas frequently extend into the optic canal. Removing these meningiomas from the optic canal is crucial for favorable visual outcome. The authors performed a retrospective analysis of 45 patients with anterior and middle fossa meningiomas with involvement of the optic pathway in whom surgery was performed by the senior author (O.A.M.) during the period from 1993 to 2007. Extent of resection and recurrence rates were determined by pre- and postoperative MR imaging studies. Visual outcomes were evaluated with full ophthalmological examinations performed before and after surgery. Forty-five patients (31 women and 14 men) were involved in this study; their mean age was 51.6 years. Patients were followed for a mean of 29.8 months (range 6-108 months). No surgery-related death occurred. The average tumor size was 3.1 cm. Total resection of the tumor (Simpson Grade I) was achieved in 32 patients (71.1%). Gross-total resection (Simpson Grades II and III) was achieved in 13 patients (28.9%). Only 1 patient harboring a left cavernous sinus meningioma had tumor recurrence and underwent repeat resection. Meningiomas extended into 58 optic canals in these cases; 13 patients showed extension into both optic canals. Visual disturbance was the main presenting symptom in 37 patients (82.2%); 8 patients had normal vision initially. Visual improvement after surgery was seen in 21 (57%) of 37 patients and in 27 (34.6%) of 78 affected eyes. Vision remained unchanged in 48 (61.5%) of 78 eyes. Transient postoperative visual deterioration occurred in 2 eyes (2.6%), with recovery to baseline over time. Only 1 (1.3%) of 78 eyes had permanent visual deterioration after surgery. The visual outcome was affected mainly by the tumor size, the preoperative visual status, and the duration of symptoms. Involvement of the optic canal in meningiomas is frequent. It occurs in a wide variety of anterior skull base meningiomas and it can be bilateral. It is a prominent factor that affects the preoperative visual status and postoperative recovery. Decompression of the optic canal and removal of the tumor inside is a crucial step in the surgical management of these tumors to optimize visual recovery and prevent tumor recurrence.

Determinants of postoperative visual recovery in suprasellar meningiomas

Suprasellar meningiomas usually present with visual deterioration, including decreased visual acuity and/or visual field defects. Suprasellar meningiomas have a close relationship with the optic apparatus, arteries of the anterior circulation, pituitary stalk and hypothalamus, which makes safe surgical resection a challenge especially with dissection around an already compromised optic apparatus. In this report 21 patients operated on for a suprasellar meningioma over a 4-year period are reviewed. Postoperative outcome and visual recovery are evaluated, including analysis of its determinants. Over a 4-year period (2002-2006), patients surgically treated for suprasellar meningiomas were included in this retrospective study. All tumors were located at the tuberculum sellae and diaphragma sellae dura. Clinical and neuro-ophthalmological examinations, imaging studies, endocrinological evaluation and follow-up data were reviewed retrospectively. The influence of patient age, sex, duration of symptoms, extent of visual impairment, tumor size , extent into optic canal, consistency, operative respectability were analyzed as potential prognostic factors for postoperative visual outcome. Twenty-one patients were included in this retrospective study. Ages ranged from 25 to 65 years (mean: 43 years). All patients had visual acuity loss and visual field defects. Symptom duration ranged from 2 to 36 months (mean: 17 months). Tumor removal was complete in 17 patients, and subtotal resection was performed in four patients. There was one case of postoperative mortality. The follow-up duration ranged from 24 to 48 months (mean: 28 months). At the last follow-up 12 patients (60%) had achieved visual improvement, whereas vision was unchanged in eight patients (40%). None of the patients had visual deterioration during their follow-up. A univariate analysis of clinical and surgical parameters thought to be related to visual outcome showed that the duration of symptoms, preoperative visual status, tumor size and adherence to the internal carotid arteries and/or anterior cerebral artery had a significant impact on visual outcome. The extent and duration of visual symptoms, size of the tumor and vascular adherence were prognostic factors affecting visual recovery after microsurgical resection of suprasellar meningiomas.

Visual recovery following optic nerve decompression for chronic compressive neuropathy

Visual failure due to optic nerve compression is a common indication for decompressive surgery. Most data only refer to the odds of improvement, deterioration or remaining the same. However, patients frequently wish to know more detail about the outcomes of surgery. Our aim was to assess the visual outcome from optic nerve decompression for visual failure in detail in order to help counsel patients pre-operatively. Sixty-eight patients undergoing 71 operations to decompress 87 optic nerves between 1991 and 2007 were identified. Thirty-four decompressions were performed via a transzygomatic and 37 via a transbasal approach. Fifty-two patients had meningiomas, 3 pituitary adenomas, 3 craniopharyngiomas, 3 chordomas, 2 adenocarcinomas, 2 fibrous dysplasia, 1 schwannoma, 1 granular pituitary tumour and 1 olfactory neuroblastoma. Visual acuity and fields were recorded pre-operatively, immediately post-operatively, at first follow-up and at most recent follow-up. Forty-three eyes (49.4%) experienced an improvement in either acuity or fields. Twenty-four (27.5%) were unchanged and 20 (22.9%) deteriorated. Average improvement was 0.88 Snellen lines (logMAR 0.13). Improvement was seen between immediate post-operative acuity and first follow-up in 52%, but 22% suffered a late deterioration after 1 year. There was no relationship between age, duration of symptoms, pathology, approach or redo surgery and visual outcome. There was a complex relationship between pre-operative visual acuity and post-operative improvement and outcome. Better pre-operative acuity predicted better outcome and greater odds of improvement, although patients with poor pre-operative vision had a greater average magnitude of improvement. Patients experience significant benefit from optic nerve decompression irrespective of pre-operative visual status. Although early decompression is desirable, good results can still be obtained in patients with severe visual failure. Detailed data on visual outcome can help counsel patients pre-operatively to aid decision-making and set expectations.

High incidence of optic canal involvement in tuberculum sellae meningiomas: rationale for aggressive skull base approach

Background Current literature on TSMs underemphasizes the significance of OCI by the tumor. In this study, we aimed to document the incidence of OCI, its management using a SBT, and its significance with relation to the visual outcome. Methods Thirty-one patients with TSM were retrospectively analyzed. In 28 patients, SBT consisting of extradural anterior clinoidectomy with falciform ligament and optic nerve sheath opening was performed. Pre- and postoperative visual status was analyzed with respect to OCI. Results The incidences of OCI and preoperative visual deficit (VD) were 77.4% and 83.8%, respectively. With regard to preoperative visual status, OCI incidence was 84.6% in 26 patients with VD compared to 40% in 5 patients without ( P = .016). Among the 23 patients with VD and detailed postoperative neuroopthalmologic evaluation, 78.3% had visual improvement; and in 21.7%, vision was unchanged on the operated side. In one patient (3.2% in the whole series), vision deteriorated on the side contralateral to the side of surgery. In the presence of OCI in 20 patients, vision improved in 80% and remained unchanged in 20%, whereas 1 of the 3 patients without OCI improved and the other 2 remained unchanged. Simpson grade I or II resection was achieved in 83.8%. Conclusion Optic canal involvement is very common in TSM (77.4%), and it correlates well with preoperative visual status. With the use of SBT, without which the tumor in the optic canal could not have been removed completely and safely, visual improvement of 78.3% and stability of 21.7% were achieved on the operated side.

Fronto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term visual outcome

We report our experience with the treatment of tuberculum sellae meningiomas using the fronto-basal interhemispheric approach. A retrospective analysis was performed on a series of 24 patients with tuberculum sellae meningiomas who were operated between March 2000 and January 2007. Patients' presenting symptoms, radiological images, operative reports, and clinical follow-up data were reviewed with special consideration for visual outcome. Visual deterioration was the presenting symptom in all patients, followed by headache in 9 patients (37.5%). The average duration of visual symptoms was 17.6 months. The average tumor diameter was 2.63 cm; encasement of the carotid artery was identified in 7 patients (29%). Complete tumor removal was achieved in 21 patients (87.5%). Mean follow-up period was 52 months. Vision improved in 19 patients (79%), remained stable in 4 (17%) and deteriorated in 1 patient (4%). The degree of tumor removal or visual outcome were both unrelated to the tumor size (p = 0.2 and p = 0.6 respectively). While the degree of preoperative visual deficit did not affect the visual improvement rate in the whole group (p = 0.9), those patients with improvement to good functional vision (>20/40) after the surgery, had a less severe preoperative deficit (p < 0.001). The most common complication was anosmia (29.1%) and there was no mortality. The frontobasal interhemispheric approach is safe and provides a direct anatomical approach to tuberculum sellae meningiomas with relatively low incidence of complications. Patients with improved vision to good functional level had a better preoperative visual status.

Assessment of visual gain following cataract surgeries in oman: a hospital-based cohort study.

The post-operative vision is used as benchmark to determine the quality of cataract surgery. However, late presentation and co-morbidities influence the visual gain and they should also be considered while auditing cataract surgeries. The authors present method of analysis of cataract surgeries for older than 30 years of aged patients performed by ophthalmologists in Oman during 2003. Ophthalmologists evaluated visual and ocular status of eyes with cataract. Cataract was operated using operative microscope and lens was implanted in the eye. The vision was recorded six weeks after surgery and visual gain was grouped from postoperative vision in relation to the preoperative vision. Presence of co-morbidities like glaucoma, corneal opacities, macular degenerations and others were considered while evaluating visual outcomes. 3,485 eyes operated were included in our study. 3,003 (86.2%) of them were operated by extra-capsular cataract extraction and lens implantation. Following surgery, 960 (27.5%) eyes had vision ³6/18. 1,483 (42.6%) eyes had vision between 6/60 and 6/18. 233 (6.8%) eyes had vision <3/60. Excellent grade of vision gain in relation to preoperative visual status was found in 2,250 (64.6%) eyes, 'good' visual gain was in 422 (12.1%) eyes and 'poor' visual gain was in 335 (9.6%) eyes. Postoperative visual status was significantly associated to the co-morbidities. (p<0.001). Nearly 14% of persons were lost to the follow up. In countries like Oman with high prevalence of trachoma, glaucoma and diabetes, the proposed grading of visual gain that accounts for the preoperative vision and the presence of co-morbidity could be better option for auditing the cataract surgery.

High incidence of optic canal involvement in clinoidal meningiomas: rationale for aggressive skull base approach

Literature specifically focusing on clinoidal meningiomas is scant, particularly with regards to the postoperative visual outcome. In this study, we aimed to document the incidence of optic canal involvement (OCI) by the tumor, its management using a skull base technique, and its significance with relation to the visual outcome. Fifty-two patients with clinoidal meningiomas were retrospectively analyzed. In 47 patients, skull base technique consisting of extradural anterior clinoidectomy with falciform ligament and optic nerve sheath opening was performed. Pre-operative visual status and post-operative outcome were analyzed with respect to OCI. The incidences of OCI was present in 19 (36%) and pre-operative visual deficit (VD) in 24 (46%) patients. With regard to pre-operative visual status, OCI was seen in 14 (58%) of 24 patients with VD, as compared to five (18%) in 28 patients without (p = 0.004). Among the 22 patients with VD and detailed postoperative neuro-ophthalmological evaluation, 17 (77%) had visual improvement, and in five patients (23%), vision was unchanged. In the presence of OCI in 11 patients, vision improved in seven (64%), and remained unchanged in four patients (36%), whereas all but one of the 11 patients (91%) without OCI improved and in the remaining one (9%), remained unchanged. Simpson Grade I and II resection was achieved in 71%. OCI is observed in 36% of clinoidal meningiomas, and it correlates well with pre-operative visual status. With the use of the skull base technique, without which the tumor in the optic canal could not have been removed completely and safely, visual improvement of 77% and stability of 23% was achieved.

Use of Cataract Services in Eastern Africa—A Study from Tanzania

Purpose: To establish the proportion of patients who are blind or have low vision prior to undergoing cataract surgery at tertiary referral centers in Tanzania. To assess which patient groups presenting for cataract surgery are more likely to be blind or visually impaired. Methods: Using pre-existing computerized audit systems we gathered data on pre-operative visual status, age, gender and presentation mode (walk-in or outreach) for 3765 patients undergoing 4258 cataract operations at 2 hospitals in Tanzania. Visual status was defined based on vision in the better eye. Results: 32% of operations were performed on blind patients, 37% on patients with low vision and 31% on normally sighted patients. Predictors of blindness at presentation were: female sex (OR 1.15; 95% CI 1.00–1.32); referral from a rural outreach program (OR 1.75; 95% CI 1.51–2.02) and older age (OR 1.02; 95% CI 1.01–1.02). Conclusions: It is not only the blind who present to cataract services in Tanzania. The demand for surgery amongst patients who or are normally sighted represents a positive move towards prevention, and not only cure of cataract blindness in Tanzania. However, it also highlights the need to target those left blind from cataract in order to deliver services to those most in need. Cataract programs targeting patients in rural areas and older patients are likely to increase the number of blind patients benefiting from cataract services.

Surgical Strategy for Tuberculum Sellae Meningiomas

The surgical strategies and outcomes for 85 patients operated on for tuberculum sellae meningioma were analyzed retrospectively. The analysis was based on factors that probably determined the difficulties encountered during surgery, assisted in predicting the extent of resectability, and helped in predicting the surgical outcome. Eighty-five patients with tuberculum sellae meningiomas were operated on in the Neurosurgery Department at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Bombay, India, between January 1989 and December 2003. The patients were analyzed retrospectively on the basis of clinical and radiologic factors that seemed to affect the outcome. Each factor was given points, and for each tumor, the points were added to obtain a score. On the basis of the score, the tumors were then divided into 3 grades. The grades determined the difficulties that could be anticipated during surgery. Most patients were operated on by means of a unifrontal craniotomy on the side of worse vision using standard dissection techniques. Total tumor resection was achieved in 72 patients, and subtotal tumor resection with less than 7% of tumor left behind was achieved in 13 patients. All patients with subtotal resection had higher grade tumors. Preoperative visual status had a bearing on the visual outcome after surgery. Four patients were misdiagnosed as having a pituitary tumor. Two patients died in the immediate postoperative period. The average follow-up was 48 months (range: 6 months to 9 years). There was symptomatic recurrence in 1 patient in whom subtotal resection had been performed. The extent and duration of visual symptoms, encasement of the anterior cerebral artery complex, and size of the tumor were the most important factors affecting surgery. The grading system provided a reasonable assessment concerning the possible surgical problems.