Visual and Hormone Outcomes in Pituitary Apoplexy: Results of a Single Surgeon, Single Institution 15-Year Retrospective Review and Pooled Data Analysis

Abstract Introduction Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. Our institutional practice consists of early surgery; therefore, we reviewed our series evaluating vision outcomes, hormone function, and complications compared with the present literature. Methods We retrospectively reviewed our institution's medical records to identify pituitary apoplexy patients who were treated via the endoscopic endonasal approach by a single neurosurgeon (senior author). We recorded basic demographics, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. Pooled data analysis of visual outcomes in the current literature using Bayesian inference was performed. Results We identified 44 patients with histologically confirmed pituitary apoplexy treated by endoscopic transsphenoidal decompression; 77% were treated within 24 hours of presentation. Total 45% had cranial nerve (CN) palsy, 36% anopsia, and 20% had visual acuity deficits. Postoperatively, 100% of CN palsies improved, 81% of anopsias improved, and 66.7% of visual acuity deficits improved. Long-lasting panhypopituitarism (25%) and hypothyrodism (22%) were common. Cavernous sinus involvement predicted residual tumor (p = 0.006). Pooled Bayesian inference showed 30% improvement in vision outcomes with surgical management compared with medical management with a number needed to treat of 3.3. Conclusion Early surgery for pituitary apoplexy was associated with excellent visual outcomes and the need for long-term hormone replacement is common. Cavernous sinus involvement is an independent predictor of residual tumor. Pooled statistical analysis favors aggressive surgical management of apoplexy for improved visual outcomes.

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Pseudophacocele following a Bicycle Handle Injury: A Case Report

Nepalese Journal of Ophthalmology ◽

10.3126/nepjoph.v10i1.21724 ◽

2018 ◽

Vol 10 (1) ◽

pp. 94-97

Author(s):

Sahil Thakur ◽

Parul Ichhpujani ◽

Suresh Kumar

Keyword(s):

Visual Acuity ◽

Case Report ◽

Blunt Trauma ◽

Surgical Management ◽

Clinical Course ◽

Rare Complication ◽

Vitreous Haemorrhage ◽

Visual Outcomes ◽

Subconjunctival Space ◽

The Right

Background: Pseudophacocele is a rare complication of blunt trauma in pseudophakic eyes.Case: We present a case of 60-year-old male who presented with pseudophacocele after injury from a bicycle handle. On presentation, visual acuity in the right eye was perception of light (PL) in 2 quadrants (superior and temporal) and left eye was 20/20. A PCIOL was seen superonasally in the right subconjunctival space with total hyphaema. Ultrasound demonstrated vitreous haemorrhage with membranes in right eye. We describe the surgical management and further clinical course of the patient.Conclusion: It is imperative to surgically manage these challenging cases. Despite optimum care visual outcomes are guarded in patients with severe blunt trauma.

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Radiological and clinical outcomes of pituitary apoplexy: comparison of conservative management versus early surgical intervention

Journal of Neurosurgery ◽

10.3171/2020.9.jns202899 ◽

2021 ◽

pp. 1-9

Author(s):

Matthew J. Shepard ◽

M. Harrison Snyder ◽

Sauson Soldozy ◽

Leonel L. Ampie ◽

Saul F. Morales-Valero ◽

...

Keyword(s):

Clinical Outcomes ◽

Median Time ◽

Conservative Management ◽

Pituitary Apoplexy ◽

Surgical Intervention ◽

Early Surgery ◽

High Dose ◽

Visual Outcomes ◽

Early Surgical Intervention

OBJECTIVE Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. However, some patients may have good clinical outcomes without surgery. The authors sought to compare the radiological and clinical outcomes of patients with PA who were managed conservatively versus those who underwent early surgery. METHODS Patients with symptomatic PA were identified. Radiological, endocrinological, and ophthalmological data were reviewed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients without visual symptoms or whose symptoms improved on high-dose steroids were treated conservatively. Log-rank and univariate analysis compared clinical and radiological outcomes between those receiving early surgery and those who underwent intended conservative management. RESULTS Sixty-four patients with PA were identified: 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA; 64.7% vs 27.7%, p = 0.009); visual field (VF) deficits (64.7% vs 19.2%, p = 0.002); and cranial neuropathies (58.8% vs 29.8%, p < 0.05) at presentation. Tumor volumes were greater in the early surgical cohort (15.1 ± 14.8 cm3 vs 4.5 ± 10.3 cm3, p < 0.001). The median clinical and radiological follow-up visits were longer in the early surgical cohort (70.0 and 64.4 months vs 26.0 and 24.7 months, respectively; p < 0.001). Among those with VA/VF deficits, visual outcomes were similar between both groups (p > 0.9). The median time to VA improvement (2.0 vs 3.0 months, p = 0.9; HR 0.9, 95% CI 0.3–3.5) and the median time to VF improvement (2.0 vs 1.5 months; HR 0.8, 95% CI 0.3–2.6, p = 0.8) were similar across both cohorts. Cranial neuropathy improvement was more common in conservatively managed patients (HR 4.8, 95% CI 1.5–15.4, p < 0.01). Conservative management failed in 7 patients (14.9%) and required surgery. PA volumes spontaneously regressed in 95.0% of patients (38/40) with successful conservative management, with a 6-month regression rate of 66.2%. Twenty-seven patients (19 in the conservative and 8 in the early surgical cohorts) responded to a prospectively administered Visual Function Questionnaire-25 (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative 95.5 ± 3.8, surgery 93.2 ± 5.1, p = 0.3). Younger age, female sex, and patients with VF deficits or chiasmal compression were more likely to experience unsuccessful conservative management. Surgical outcomes were similar for patients receiving early versus delayed surgery. CONCLUSIONS These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available.

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Surgical Management of Primary Cavernous Sinus Tumors

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0033-1336353 ◽

2013 ◽

Vol 74 (S 01) ◽

Cited By ~ 1

Author(s):

Maria Koutourousiou ◽

George Zenonos ◽

Juan Fernandez-Miranda ◽

Eric Wang ◽

Carl Snyderman ◽

...

Keyword(s):

Surgical Management ◽

Cavernous Sinus

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1097-P: Glycemic Control and Safety Profile of Insulin Glargine 300 U/mL in Older Adults—REALI Pooled Data Analysis

Diabetes ◽

10.2337/db19-1097-p ◽

2019 ◽

Vol 68 (Supplement 1) ◽

pp. 1097-P

Author(s):

RICCARDO C. BONADONNA ◽

DIDAC MAURICIO ◽

DIRK MÜLLER-WIELAND ◽

NICK FREEMANTLE ◽

GREGORY BIGOT ◽

...

Keyword(s):

Older Adults ◽

Data Analysis ◽

Glycemic Control ◽

Insulin Glargine ◽

Safety Profile ◽

Pooled Data

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Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1722993 ◽

2021 ◽

Author(s):

John T. Butterfield ◽

Takako Araki ◽

Daniel Guillaume ◽

Ramachandra Tummala ◽

Emiro Caicedo-Granados ◽

...

Keyword(s):

Pituitary Adenomas ◽

Pituitary Apoplexy ◽

Residual Tumor ◽

Extent Of Resection ◽

Morbidity And Mortality ◽

Surgical Approaches ◽

Subtotal Resection ◽

Advantages And Disadvantages ◽

Cranial Nerve Palsies ◽

Giant Pituitary Adenomas

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

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Incidence, Risk, and Visual Outcomes after Repositioning of Acute Non-Traumatic Flap Dislocations Following Femtosecond-Assisted LASIK

Journal of Clinical Medicine ◽

10.3390/jcm10112478 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2478

Author(s):

Majid Moshirfar ◽

David G. West ◽

Chase M Miller ◽

William B. West ◽

Shannon E. McCabe ◽

...

Keyword(s):

Risk Factors ◽

Visual Acuity ◽

High Myopia ◽

Case Series ◽

Retrospective Case ◽

Visual Outcomes ◽

Uncorrected Distance Visual Acuity ◽

Incidence Risk ◽

Mechanical Devices

Although the use of femtosecond lasers instead of mechanical devices has decreased the incidence of flap complications following laser-assisted in situ keratomileusis (LASIK), dislocations and striae still occur. Flap repositioning is an effective intervention to improve visual outcomes after acute flap complications in both microkeratome-assisted and femtosecond-assisted LASIK. This retrospective case series included patients undergoing flap repositioning secondary to acute flap dislocation and/or visually significant striae within the first two weeks following femtosecond LASIK (FS-LASIK) from 2015 to 2020 at a single institution. Preoperative, intraoperative, and postoperative de-identified data were analyzed for incidence, risk factors, and visual acuity outcomes. The incidence of flap repositioning was 0.35% in 21,536 eyes (n = 70). Indications for repositioning included acute flap dislocation (35.7%) and visually significant striae (64.3%). High myopia (OR = 3.04, p = 0.001) and patient age over 50 years (OR = 3.69, p = 0.001) were the strongest risk factors for these complications. Prior to flap repositioning, uncorrected distance visual acuity (UDVA) of 20/20 or better and 20/40 or better occurred in 19% and 57% of eyes, respectively. After repositioning, a final UDVA of 20/20 or better and 20/40 or better occurred in 78% and 98% of eyes, respectively. After repositioning, one line of UDVA was lost in two eyes (2.8%) and two lines were lost in one eye (1.4%). Risk factors for acute flap dislocation included high myopia and age over 50 years. Flap repositioning was effective in salvaging visual outcomes.

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Impact of Age on the Effectiveness and Safety of Insulin Glargine 300 U/mL: Results from the REALI European Pooled Data Analysis

Diabetes Therapy ◽

10.1007/s13300-021-01030-0 ◽

2021 ◽

Author(s):

Riccardo C. Bonadonna ◽

Didac Mauricio ◽

Dirk Müller-Wieland ◽

Nick Freemantle ◽

Gregory Bigot ◽

...

Keyword(s):

Data Analysis ◽

Insulin Glargine ◽

Pooled Data

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Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1726018 ◽

2021 ◽

Author(s):

Gianluca Agresta ◽

Alberto Campione ◽

Fabio Pozzi ◽

Pierlorenzo Veiceschi ◽

Martina Venturini ◽

...

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Conformal Radiotherapy ◽

Residual Tumor ◽

Complete Recovery ◽

Tumor Location ◽

Transsphenoidal Approach ◽

Low Grade ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction

Abstract Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots (Fig. 1). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus (Fig. 2) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus (Fig. 1). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.The link to the video can be found at: https://youtu.be/TsqXjqpuOws.

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Surgical management and outcomes of pediatric open globe injuries requiring vitrectomy

European Journal of Ophthalmology ◽

10.1177/11206721211000648 ◽

2021 ◽

pp. 112067212110006

Author(s):

Xin Liu ◽

Lufei Wang ◽

Fengjuan Yang ◽

Jia’nan Xie ◽

Jinsong Zhao ◽

...

Keyword(s):

Visual Acuity ◽

Surgical Management ◽

Pediatric Patients ◽

Vitreous Hemorrhage ◽

Visual Outcome ◽

Poor Visual Outcome ◽

Early Vitrectomy ◽

Open Globe ◽

Time From Injury ◽

Ocular Sign

Purpose: To describe surgical management and establish visual outcomes of open globe injury (OGI) in pediatric patients requiring vitrectomy. Methods: Forty-eight eyes of 48 pediatric patients underwent vitrectomy for OGI with secondary vitreoretinal complications in the eye center of Jilin University were included. Characteristics of patients, details of ocular examination and operation, presenting and final visual acuity were recorded. Results: Presenting visual acuity less than 20/400 was found in 44 eyes (91.7%), which included no light perception (NLP) in four eyes. At last visit, there was no eyes with visual acuity of NLP, and 19 eyes (39.6%) had a vision recovery to 20/400 or better. Mechanisms of injury, intraocular contents prolapse, presence of hyphema, intraocular foreign body, vitreous hemorrhage, retinal detachment, and total time from injury to PPV > 2 weeks were significant predictors of visual prognosis. Logistic regression analysis showed that hyphema was a significant predictive factor for poor visual outcome. Conclusion: Visual acuity was improved in most of the patients with OGI in this study. Hyphema is an important presenting ocular sign in estimating the post-vitrectomy visual outcome for OGI in children. Proper timing of vitrectomy is suggested, and in this study patients may benefit more with early vitrectomy as less proliferative vitreoretinopathy (PVR) was found together with a better visual acuity.

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Intraoperative choroidal detachment during small-gauge vitrectomy: analysis of causes, anatomic, and visual outcomes

Eye ◽

10.1038/s41433-021-01605-y ◽

2021 ◽

Author(s):

Ting Zhang ◽

Yantao Wei ◽

Zhaotian Zhang ◽

Wei Chi ◽

Lujia Feng ◽

...

Keyword(s):

Visual Acuity ◽

Medical Records ◽

Demographic Characteristics ◽

Choroidal Detachment ◽

Fluid Exchange ◽

Visual Outcomes ◽

Corrected Visual Acuity ◽

Ocular Hypotony ◽

Small Gauge ◽

Best Corrected Visual Acuity

Abstract Introduction To investigate the incidence and causes of intraoperative choroidal detachment (CD) during small-gauge vitrectomy, as well as the anatomic and visual outcomes. Methods We retrospectively reviewed the medical records of 1026 consecutive patients who underwent small-gauge vitrectomy from June 2017 to December 2018 at Zhongshan Ophthalmic Centre, Guangzhou, China. Data on the presence, location, and extent of intraoperative CD and its relationship to the infusion cannula were collected. Patient demographic characteristics and postoperative anatomic and visual outcomes were also assessed. Results A total of six cases were found to have intraoperative CD, including two with serous CD, three with limited haemorrhagic CD, and one with CD caused by inadvertent perfusion of gas during air/fluid exchange. Retraction of the infusion cannula and acute ocular hypotony were found to be the main causes of intraoperative CD in five out of the six cases. The best-corrected visual acuity of all cases significantly improved after the surgery. Conclusion The incidence of intraoperative CD during small-gauge vitrectomy is low; the predominant causes are retraction of the infusion cannula and acute ocular hypotony. Immediate awareness and timely closure of the incision may contribute to a better surgical prognosis.

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