Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes

2021 ◽  
pp. 1-11
Author(s):  
Joseph A. Carnevale ◽  
Christopher S. Babu ◽  
Jacob L. Goldberg ◽  
Reginald Fong ◽  
Theodore H. Schwartz
Keyword(s):  
Vision Loss ◽  
Rare Event ◽  
Visual Outcome ◽  
Supplemental Oxygen ◽  
Senior Author ◽  
Endoscopic Endonasal ◽  
Blood Pressure Elevation ◽  
Visual Deterioration ◽  
Associated Risk Factors ◽  
Early Reoperation

OBJECTIVE Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood. METHODS The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods. RESULTS Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits. CONCLUSIONS Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

scholarly journals Endonasal endoscopic transsphenoidal chiasmapexy using a clival cranial base cranioplasty for visual loss from massive empty sella following macroprolactinoma treatment with bromocriptine: case report

2016 ◽  
Vol 124 (4) ◽  
pp. 1025-1031 ◽  
Author(s):  
G. Rene Alvarez Berastegui ◽  
Shaan M. Raza ◽  
Vijay K. Anand ◽  
Theodore H. Schwartz
Keyword(s):  
Case Report ◽  
Visual Loss ◽  
Rare Event ◽  
Empty Sella ◽  
Functional Improvement ◽  
Endoscopic Endonasal ◽  
Lumbar Drainage ◽  
Visual Deterioration ◽  
Giant Prolactinoma ◽  
History Of

Visual deterioration after dopamine-agonist treatment of prolactinomas associated with empty sella syndrome and secondary optic apparatus traction is a rare event. Chiasmapexy has been described as a viable treatment option, although few cases exist in the literature. Here, a novel endonasal endoscopic approach to chiasmapexy is described and its efficacy is demonstrated in a case report. A 55-year-old female patient with a history of a giant prolactinoma and 14 years of treatment using dopaminergic agonist therapy presented to our institution with a 1-month history of visual changes. Neuroophthalmological examination confirmed severe bitemporal field defects, and MRI revealed a large empty sella with downward optic chiasmal herniation. Endoscopic endonasal chiasmapexy was performed by elevating the chiasm with lumbar drainage and filling the clival and sellar defect with an extradural liquid (HydroSet; a cranioplasty bone cement), and a piece of AlloDerm was used to cover and cushion the chiasm. Postoperative imaging demonstrated successful anatomical elevation of the optic apparatus, and the patient showed functional improvement in the visual field at 3 months postoperatively. Although rare, massive empty sellar and chiasmal descent from macroadenoma treatment can result in progressive visual loss. Here, a novel technique of endonasal endoscopic extradural cranioplasty aided by lumbar drainage is reported, which appears to be an effective technique for stabilizing and possibly reversing anatomical and visual deterioration.

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

2011 ◽  
Vol 30 (5) ◽  
pp. E12 ◽  
Author(s):  
Ahmed Nageeb M. Taha ◽  
Kadir Erkmen ◽  
Ian F. Dunn ◽  
Svetlana Pravdenkova ◽  
Ossama Al-Mefty
Keyword(s):  
Tumor Size ◽  
Tumor Recurrence ◽  
Visual Outcome ◽  
Senior Author ◽  
Optic Canal ◽  
Recurrence Rates ◽  
Total Resection ◽  
Duration Of Symptoms ◽  
Visual Deterioration ◽  
Visual Status

Object Juxtasellar meningiomas frequently extend into the optic canal. Removing these meningiomas from the optic canal is crucial for favorable visual outcome. Methods 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. Results 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. Conclusions 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.

scholarly journals ‘Failure’ of laser prophylaxis in an eye with stickler syndrome

2021 ◽  
Vol 11 (4) ◽  
pp. 110-111
Author(s):  
Michael P Blair
Keyword(s):  
Vision Loss ◽  
Clinical Course ◽  
Case Reports ◽  
Visual Outcome ◽  
Stickler Syndrome ◽  
Connective Tissue Disorders ◽  
Macular Function ◽  
Giant Retinal Tear ◽  
Case Summary

Background: Stickler syndrome is one of the most common inherited connective tissue disorders and is an important cause of pediatric vision loss due to a high risk of retinal detachment in these patients. Methods: Case report. Case summary: This case reports describes the clinical course of a 10 year old boy with Sticklers Syndrome who underwent bilateral peripheral laser prophylaxis. During routine follow up, he was found to have an asymptomatic giant retinal tear (GRT) with limited sub-retinal fluid expansion due to prior prophylactic laser. He underwent surgery with vitrectomy and scleral buckle with vision remaining at 20/25 at 6 month follow up. Conclusion: Although the utility of laser prophylaxis in Stickler patients is debated, this case demonstrates that after laser prophylaxis, even if GRT develops, expansion can be limited. Laser prophylaxis along with frequent examinations, can prevent development of PVR and complex detachments and preserve macular function with excellent visual outcome.

Visual Outcome of Tuberculum Sellae Meningiomas after Extradural Optic Nerve Decompression

Neurosurgery ◽  
2006 ◽  
Vol 59 (3) ◽  
pp. 570-576 ◽  
Author(s):  
Tiit Mathiesen ◽  
Lars Kihlström
Keyword(s):  
Cerebrospinal Fluid ◽  
Optic Nerve ◽  
Diabetes Insipidus ◽  
Visual Outcome ◽  
Optic Canal ◽  
Visual Deterioration ◽  
Nerve Decompression ◽  
Visual Outcomes ◽  
Tuberculum Sellae

Abstract OBJECTIVE: Meningiomas of the tuberculum sellae have a close relationship with the optic apparatus. Even modern series show a 10 to 20% risk of visual deterioration after surgery. We have attempted to improve visual outcome by extradural decompression of the optic canal and anterior clinoid process, followed by intradural release of the optic nerve; this study provides an analysis of visual outcomes with this approach. METHODS: Treatment, histopathology, and follow-up data of 29 consecutive patients undergoing surgery for tuberculum sellae meningiomas with initial release of the optic nerve were prospectively collected. RESULTS: Radical tumor removal was possible in all 23 patients with primary tumors and in three out of six patients with recurrent tumors. All patients but two of the worst affected with preoperative visual compromise improved from surgery; there were no instances of visual deterioration. Five patients with normal preoperative vision remained intact and visual improvement was 22 (91%) out of 24 patients in the remaining patients. In total, 13 patients (42%) had completely normal vision at follow-up. Mainly patients younger than 60 years experienced complete normalization after surgery. Two patients underwent transsphenoidal surgery for cerebrospinal fluid leaks. Postoperative endocrinological symptoms were temporary diabetes insipidus in one patient and permanent diabetes insipidus in another patient undergoing elective sectioning of the pituitary stalk because of a recurrent tumor with invasive growth into the stalk. CONCLUSION: Adding early optic nerve decompression by extradural clinoidectomy and optic canal unroofing to a frontopterional approach seemed to improve visual outcomes because there were no instances of visual deterioration. Simpson Grade 1 to 2 removal was possible in all patients with primary surgery, whereas recurrent cases could only be treated with lower grades of radicality. Radical removal, however, required readiness to reoperate for cerebrospinal fluid leakage at the site of the drilled tumor origin in bone.

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension

2021 ◽  
pp. 1-7
Author(s):  
Gad Dotan ◽  
Natalie Hadar Cohen ◽  
Hanya M. Qureshi ◽  
Mika Shapira Rootman ◽  
Yoram Nevo ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Vision Loss ◽  
Symptom Relief ◽  
Visual Outcome ◽  
Fiber Layer ◽  
Lumbar Drainage ◽  
Lumbar Drain ◽  
Rnfl Thickness ◽  
External Lumbar Drainage

OBJECTIVE Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. METHODS The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. RESULTS The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20–30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3–29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. CONCLUSIONS ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

scholarly journals P.093 Visual outcomes after expanded endoscopic endonasal resection of suprasellar meningiomas and optic nerve decompression

2019 ◽  
Vol 46 (s1) ◽  
pp. S38
Author(s):  
K Yang ◽  
Y Ellenbogen ◽  
J Kim ◽  
A Rodriguez ◽  
D Sommer ◽  
...  
Keyword(s):  
Visual Acuity ◽  
Optic Nerve ◽  
Visual Outcome ◽  
Symptom Duration ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Visual Symptoms ◽  
Nerve Decompression ◽  
Optic Nerve Decompression

Background: The Endoscopic endonasal approach (EEA) has become increasingly popular in the treatment of suprasellar meningiomas, which often cause visual symptoms due to compression of the anterior optic apparatus. Methods: We performed a retrospective chart review on patients who underwent EEA optic nerve decompression and resection of suprasellar meningiomas between January 1st 2005 and December 1st 2018 at McMaster University. Results: The mean age of our patients was 59.8 years. We treated 9 male and 23 female patients, with a mean follow up of 6.29 years. 23 patients (71.9%) presented with visual symptoms, with a mean duration of 8.65 months. In our patient cohort, 95.5% had stable or improved visual acuity postoperatively. Less than six months of visual decline was more likely to be associated with postoperative improvement of visual acuity, with an odds ratio (OR) of 0.0222 (95% CI: 0.0017–0.289, p<0.05); as well as visual field (OR:0.0625; 95% CI, 0.0042–0.915, p<0.05). Additionally, the absence of RAPD was associated with improved postoperative visual acuity (OR: 0.0675; 95% CI, 0.0354–0.706, p<0.05). Conclusions: Endoscopic endonasal approach can achieve good visual outcome in patients harboring suprasellar meningiomas. Symptom duration of less than six months and absence of RAPD were positive predictor of postoperative visual outcome.

Visual Outcome After Extended Endoscopic Endonasal Transsphenoidal Surgery for Tuberculum Sellae Meningiomas

2010 ◽  
Vol 73 (6) ◽  
pp. 694-700 ◽  
Author(s):  
Qing Wang ◽  
Xiao-Jie Lu ◽  
Wei-Ying Ji ◽  
Zheng-Cun Yan ◽  
Jia Xu ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Visual Outcome ◽  
Endoscopic Endonasal ◽  
Endoscopic Endonasal Transsphenoidal Surgery ◽  
Tuberculum Sellae

Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma

2020 ◽  
Author(s):  
Arad Iranmehr ◽  
Mostafa Esmaeilnia ◽  
Khashayar Afshari ◽  
Seyed Mousa Sadrehosseini ◽  
Azin Tabari ◽  
...  
Keyword(s):  
Tumor Resection ◽  
Visual Outcome ◽  
Extent Of Resection ◽  
Csf Leak ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Pituitary Dysfunction ◽  
Before And After

Abstract Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

Population-based assessment of visual acuity outcomes following cataract surgery in Australia: the National Eye Health Survey

2018 ◽  
Vol 102 (10) ◽  
pp. 1419-1424 ◽  
Author(s):  
Stuart Keel ◽  
Jing Xie ◽  
Joshua Foreman ◽  
Hugh R Taylor ◽  
Mohamed Dirani
Keyword(s):  
Visual Acuity ◽  
Cataract Surgery ◽  
Vision Loss ◽  
Indigenous Population ◽  
Postoperative Outcome ◽  
Visual Outcome ◽  
National Sample ◽  
Population Based ◽  
Indigenous Populations ◽  
Indigenous Australians

AimTo assess the visual outcomes of cataract surgery among a national sample of non-Indigenous and Indigenous Australians.MethodsThis was a population-based study of 3098 non-Indigenous Australians (50–98 years) and 1738 Indigenous Australians (40–92 years), stratified by remoteness. A poor postoperative outcome in an eye that had undergone cataract surgery was defined as presenting distance visual acuity (PVA) <6/12–6/60, and a very poor outcome was defined as PVA <6/60. Effective cataract surgery coverage (eCSC; operated cataract and a good outcome (PVA ≥6/12) as a proportion of operable plus operated cataract) was calculated.ResultsThe sampling weight adjusted cataract surgery prevalence was 19.8% (95% CI 17.9 to 22.0) in non-Indigenous Australians and 8.2% (95% CI 6.0 to 9.6) in Indigenous Australians. Among the non-Indigenous population, poor and very poor PVA outcomes were present in 18.1% and 1.9% of eyes, respectively. For Indigenous Australians, these values were 27.8% and 6.3%, respectively. The main causes of poor vision were refractive error (non-Indigenous=41.8%; Indigenous=41.9%) and coincident disease (non-Indigenous=43.3%; Indigenous=40.3%). The eCSC rates in the non-Indigenous and Indigenous populations were 88.5% (95% CI 85.2 to 91.2) and 51.6% (95% CI 42.4 to 60.7), respectively.ConclusionApproximately half of eyes with a poor visual outcome postcataract surgery could be readily avoided through the appropriate refractive correction. The finding of a lower eCSC rate among Indigenous Australians suggests that improvements in access and quality of cataract services may be warranted in order to reduce cataract-related vision loss in the Indigenous population.

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