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Table of Contents    
COMMENTARY
Year : 2016  |  Volume : 64  |  Issue : 6  |  Page : 1254-1255

Visual outcome after pituitary adenoma surgery


1 Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, United States
2 Department of Neurological Surgery; Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital; Department of Neuroscience, Weill Cornell Medical College, New York, United States

Date of Web Publication11-Nov-2016

Correspondence Address:
Sacit B Omay
Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.193770

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How to cite this article:
Omay SB, Schwartz TH. Visual outcome after pituitary adenoma surgery. Neurol India 2016;64:1254-5

How to cite this URL:
Omay SB, Schwartz TH. Visual outcome after pituitary adenoma surgery. Neurol India [serial online] 2016 [cited 2019 Jun 26];64:1254-5. Available from: http://www.neurologyindia.com/text.asp?2016/64/6/1254/193770


Pituitary adenomas are relatively common brain tumors with an estimated prevalence of 16.7%.[1] Treatment modalities are evolving with new technologies in surgery, such as fully endoscopic approaches, and increasing use of pharmacotherapy as most commonly used in prolactiomas. Vision loss has been one of the signature neurologic deficits caused by these lesions, and there have been many studies investigating the factors that that play a role in improving visual outcome after surgical decompression. Preoperative vision, the age and size of the patient, as well as the configuration of the tumor have been positively correlated to visual outcome in earlier studies.[2]

Dutta et al., in this new study, examine the visual outcome after resection of pituitary adenomas in patients having preoperative visual defects.[3] The study includes a large cohort and the authors were able to track visual outcome, visual acuity (VA), and visual fields (VFs) separately at three different time points including at discharge, at 3 months, and at 12 months. Data collection was done first retrospectively (2003–2010) and then prospectively (2011–2014) in the latter part of the study. The prospective data were available for 29.6% of the patients, and the retrospective data were obtained for 70.4% of the patients. They found that bitemporal hemianopia was the most common type of field defect (47.6%), and suprasellar extension of the tumor was present in 89.2% of the patients. A large majority of the operations were transsphenoidal (96.9%). In the initial years, a sublabial rhinoseptal approach was used, which was followed by a transnasal transseptal approach, and most recently, a direct endonasal approach.

The authors found that postoperative visual outcome was directly proportional to the preoperative VA, and that patients with better preoperative VA had better visual outcome. Eighty-two percent of the patients with less severe visual deficits had improvement in visual status, whereas only 10% of the patients with no perception of light improved.

They also noted that patients had earlier recovery of vision if the duration of symptoms was shorter. However, the ultimate outcome was good at the end of 1 year irrespective of the duration of symptoms.[3]

One of the strengths of this study is that the authors have collected VF and VA data separately. Macroadenomas typically start compressing the crossing fibers of the chiasm first, creating the typical bitemporal hemianopsia. VA changes are caused by compression of the macular fibers at a later stage of the disease.[2],[4]

Dutta et al., present their findings from this semi-prospective study of their large cohort, which makes it very valuable. It is important to note that these results are from a microscopic transsphenoidal approach, which is known to have worse visual outcomes compared with the endoscopic approach.[5]

Their finding that 93.2% of the patients had better vision at 1 year is similar to the previously reported outcomes.[6],[7] Surprisingly, the impact of advanced age as a predictor of worse visual outcome was not reproduced in this study.

During the last two decades, neurosurgical approach to pituitary tumors evolved from the microscopic approach to the endoscope assisted, and lastly to pure endonasal endocopic approaches. In the context of pituitary tumors, it has revolutionized the extent and quality of the visualization and increased the limits of surgical access to the sella and suprasellar area. The perceived limitations of the endoscopic approach such as the existence of a learning curve, and the two-dimensional vision of the endoscope can be easily overcome by working in a multidisciplinary team.[8] The endoscopic approach has been shown to be having a significantly higher gross total resection rate when compared with microscopy, particularly for pituitary tumors with cavernous sinus invasion,[9] and fewer recurrences as well as better visual outcomes.[5]

The authors rightfully emphasize the fact that early intervention on pituitary adenomas with visual deficits will not only improve visual outcome but also decrease the time to be needed to achieve improvement. The take home message here is that we as surgeons should encourage our patients to undergo surgery as soon as there is any evidence of visual loss. Observation in this situation can be harmful.

 
  References Top

1.
Ezzat S, Asa SL, Couldwell WT, Barr CE, Dodge WE, Vance ML, Mccutcheon IE. The prevalence of pituitary adenomas: A systematic review. cancer 2004;101:613-9.  Back to cited text no. 1
    
2.
Barzaghi LR, Medone M, Losa M, Bianchi S, Giovanelli M, Mortini P. Prognostic factors of visual field improvement after trans-sphenoidal approach for pituitary macroadenomas: Review of the literature and analysis by quantitative method. Neurosurg Rev 2012;35:369-78.  Back to cited text no. 2
    
3.
Dutta P, Gyurmey T, Bansal R, Pathak A, Dhandapani S, Rai A, et al. Visual outcome in 2000 eyes following microscopic transphenoidal surgery for pituitary adenomas: Protracted blindness should not be a deterrent. Neurol India 2016;64:1247-53.  Back to cited text no. 3
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4.
Jagle H, Zrenner E, Krastel H, Hart W: Dyschromatopsias associated with neuro-ophthalmic disease. clinical neuro-ophthalmology. MarionP (ed): Springer, Berlin–Heidelberg; 2007:71-88.  Back to cited text no. 4
    
5.
Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary 2012; 15:150-9.  Back to cited text no. 5
    
6.
Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005;56:1222-33.  Back to cited text no. 6
    
7.
Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: Early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 2008;62:1006-1015.  Back to cited text no. 7
    
8.
Schaberg MR, Anand VK, Schwartz TH, Cobb W. Microscopic versus endoscopic transnasal pituitary surgery. Curr Opin Otolaryngol Head Neck Surg 2010;18:8-14.  Back to cited text no. 8
    
9.
Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH. Cavernous sinus invasion in pituitary adenomas: Systematic review and pooled data meta-analysis of radiological criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 2016. 10.1016/j.wneu.2016.08.088.  Back to cited text no. 9
    



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