Optic nerve compression in craniopharyngioma by taut anterior cerebral arteries visualized in frontal and transsphenoidal exposures: illustrative cases

BACKGROUND During initial exposure and removal of craniopharyngioma in pediatric patients with severe visual field deficits, the authors have encountered severe deformation of the optic apparatus by taut anterior cerebral arteries as seen during both frontal craniotomy and transsphenoidal exposures. OBSERVATIONS The authors report two pediatric patients with craniopharyngioma whose severe preoperative visual deficits were associated not only with large suprasellar masses but also with severe optic nerve and chiasm compression by taut anterior cerebral arteries. In each patient, the optic nerves were partially cleft by these vessels’ indenting them. LESSONS The role of a taut anterior cerebral artery complex in compression of the optic apparatus in patients with suprasellar tumors has been reported previously, but the intraoperative images in these two cases dramatically reveal this phenomenon.

Cavernous Hemangioma in the Orbital Cavity: Case Report

Cavernous hemangiomas are benign malformations of vascular origin, usually well circumscribed and slow to grow. These lesions can be asymptomatic, being discovered unintentionally in imaging exams or symptomatic, indicated mainly by the presence of proptosis, diplopia, and visual disturbances by optic nerve compression. The complementary exams involve computed tomography associated with contrast, color Doppler, magnetic resonance, and angiography. Treatment can be conservative or surgical depending on the case, and the open therapy usually involves lateral, supraorbital, transconjunctival, transantral, pterional, transnasal, and extradural endoscopic orbitotomy. The present study aims to report a recurrent case of hemangioma in the orbital cavity signaled by ocular proptosis, hyperemia, and ocular pain.The lesion was achieved through the Weber-Ferguson access with zygomatic osteotomy and preservation of the infraorbital nerve. The excision of the lesion was performed, and the previously displaced fragments were fixed with 1.5 mm mini plates. The patient has a chance of progressing with visual impairment due to considerable manipulation of the optic nerve and is being followed up.The reported case showed a successful diagnosis and therapeutic conduct, remaining now in the evolution and follow-up scenario.

Strategies for Optic Pathways Decompression for Extra-Axial Tumors or Intracranial Aneurysms: A Technical Note

Background Different types of skull base tumors and intracranial aneurysms may lead to compression of the optic pathways. Since most of them are biologically benign conditions, the first aim of surgery is preservation of optic nerves rather than the oncologic radicality. Materials and methods Based on the progressive technical refinements coming from our institutional experience of optic nerve compression from aneurysms and extra-axial tumors, we analyzed the surgical steps to release nerves and chiasm during tumor debulking and aneurysm clipping. Results We distinguished vascular and tumor lesions according to the main direction of optic nerve compression: lateral to medial, medial to lateral, inferior to superior, and anterior to posterior. We also identified four fundamental sequential maneuvers to release the optic nerve, which are (1) falciform ligament (FL) section, (2) optic canal unroofing, (3) anterior clinoid process drilling, and (4) optic strut removal. The FL section is always recommended when a gentle manipulation of the optic nerve is required. Optic canal unroofing is suggested in case of lateral-to-medial compression (i.e., clinoid meningiomas), medial-to-lateral compression (i.e., tuberculum sellae meningiomas), and inferior-to-superior compression (i.e., suprasellar lesions). Anterior clinoidectomy and optic strut removal may be necessary in case of lateral-to-medial compression from paraclinoid aneurysms or meningiomas. Conclusions Preservation of the visual function is the main goal of surgery for tumors and aneurysms causing optic nerve compression. This mandatory principle guides the approach, the timing, and the technical strategy to release the optic nerve, and is principally based on the direction of the compression vector.

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’ orbitopathy.Patients and MethodsIn this observational, retrospective study, the medical charts of 24 patients (32 eyes) with a diagnosis of DON between 2008 and 2019 were included. Our goal was to identify potential pathological signs in patients with DON prior to the definitive diagnosis of DON.ResultsWe discovered that the earliest pathological sign in the subclinical cases was tritan deficiency obtained with a standardised colour vision test by Arden. In all cases but one, regardless of the visual field (VF) defects, the tritan values were pathological (based on a threshold of ≥8%) in the subclinical phase. The mean tritan value was 19.12% (range 6.9–80.8%) at the time of the subclinical phase and 32.16% (range 6.3–100.0%) at the time of the diagnosis of DON. The sensitivity of the colour vision test was 20% for protan and 96.67% for tritan in the subclinical phase. At the time of the definitive diagnosis of DON, the sensitivity of protan was 48.15% compared to 96.30% for tritan.ConclusionWe found that changes in vision affecting the blue-yellow (tritan) colours resulting from the compression of optic nerve, even in affected patients with normal VF tests, are a reliable early sign of DON.

The outcomes of conservatively observed asymptomatic nonfunctioning pituitary adenomas with optic nerve compression

OBJECTIVEThe authors investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) with optic nerve compression.METHODSThis study retrospectively analyzed the natural history of asymptomatic NFPAs with documented optic nerve compression on MRI diagnosed between 2000 and 2016 from 2 institutions. The patients were followed up with regular endocrinological, ophthalmological, and radiological evaluations, and the endpoint was new endocrinopathy or neurological deficits.RESULTSThe study comprised 81 patients. The median age at diagnosis was 58.0 years and the follow-up duration was 60.0 months. As the denominator of overall pituitary patients, 2604 patients were treated with surgery after diagnosis at the 2 institutions during the same period. The mean initial and last measured values for tumor diameter were 23.7 ± 8.9 mm and 26.2 ± 11.4 mm, respectively (mean ± SD). Tumor growth was observed in 51 (63.0%) patients; however, visual deterioration was observed in 14 (17.3%) patients. Ten (12.3%) patients experienced endocrine deterioration. Fourteen (17.3%) patients underwent surgery for either visual deterioration (in 12 patients) or endocrine dysfunction (in 2 patients). After surgery, all patients experienced improvements in visual or hormonal function. The actuarial rates of treatment-free survival at 2, 3, and 5 years were 96.1%, 93.2%, and 85.6%, respectively. In the multivariate analysis, initial cavernous sinus invasion (HR 4.985, 95% CI 1.597–15.56; p = 0.006) was the only independent risk factor for eventual treatment.CONCLUSIONSThe neuroendocrinological deteriorations were not frequent and could be recovered by surgery with early detection on regular follow-up in asymptomatic NFPAs with documented optic nerve compression on MRI. Therefore, conservative management could be an acceptable strategy for these tumors. Careful follow-up is required for tumors with cavernous sinus invasion.

ENT Disorders Presenting with Ophthalmological Manifestations:An Overview

Background: It is important to diagnose the condition early and manage aggressively. It is often difficult to cure orbital cellulitis due to late treatment and may cause blindness if left untreated because of optic nerve compression. Both orbital abscess and cavernous sinus thrombosis may lead to intracranial spread of infection, such as meningitis or cerebral abscess with high morbidity and possible mortality.Subjects and Methods:A total number of 124 cases of ophthalmological manifestation caused by various ENT diseases, mostly paranasaltumourextensions; nasopharyngeal tumour and furunculosis of nose were analyzed in a retrospective study in relation to their age, sex, clinical,radiological and histopathologicalprofile.Results: Direct nasal endoscopy(DNE), Fibre optic Flexible nasopharyngoscopy was Useful. HRCT scan was considered as the most dependable investigating tool. Different modalities of medical and surgical treatment have been adopted according to location and nature of diseases.Conclusion: Aclose co-operationand team effort required between otorhinolaryngologist and ophthalmologist to overcome this kind of challenges.