J Korean Neurosurg Soc.  2015 Jan;57(1):23-31. 10.3340/jkns.2015.57.1.23.

The Influence of Pituitary Adenoma Size on Vision and Visual Outcomes after Trans-Sphenoidal Adenectomy: A Report of 78 Cases

• Ho RW
• Huang HM
• Ho JT

• KMID: 2067087
• DOI: http://doi.org/10.3340/jkns.2015.57.1.23

Abstract

OBJECTIVE
The aims of this study were to investigate the quantitative relationship between pituitary macroadenoma size and degree of visual impairment, and assess visual improvement after surgical resection of the tumor.
METHODS
The medical records of patients with pituitary adenoma, who had undergone trans-sphenoidal adenectomy between January 2009 and January 2011, were reviewed. Patients underwent an ocular examination and brain MRI before and after surgery. The visual impairment score (VIS) was derived by combining the scores of best-corrected visual acuity and visual field. The relationship between VIS and tumor size/tumor type/position of the optic chiasm was assessed.
RESULTS
Seventy-eight patients were included (41 male, 37 female). Thirty-two (41%) patients experienced blurred vision or visual field defect as an initial symptom. Receiver operating characteristic curve analysis showed that tumors <2.2 cm tended to cause minimal or no visual impairment. Statistical analysis showed that 1) poor preoperative vision is related to tumor size, displacement of the optic chiasm in the sagittal view on MRI and optic atrophy, and 2) poorer visual prognosis is associated with greater preoperative VIS. In multivariate analysis the only factor significantly related to VIS improvement was increasing pituitary adenoma size, which predicted decreased improvement.
CONCLUSION
Results from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual impairment. Patients with a large macroadenoma or giant adenoma should undergo surgical resection as soon as possible to prevent permanent visual loss.

Keyword

Ophthalmologic surgical procedures; Pituitary adenoma; Visual fields; Visual impairment

MeSH Terms

Adenoma
Brain
Humans
Magnetic Resonance Imaging
Male
Medical Records
Multivariate Analysis
Ophthalmologic Surgical Procedures
Optic Atrophy
Optic Chiasm
Pituitary Neoplasms*
Prognosis
ROC Curve
Vision Disorders
Visual Acuity
Visual Fields

Figure

• 

  Fig. 1 Tables for calculation of the visual impairment score (VIS) using results of visual acuity and visual field deficit. Sample VIS calculation for a patient with visual acuity of 0.4 (4/10) in the left eye and 0.2 (2/10) in the right eye (visual acuity impairment score of 35), combined with bitemporal visual field deficit (visual field impairment score of 22) for a VIS of 57 is shown.14)

• 

  Fig. 2 Receiver operating characteristic (ROC) curve for identifying poor preoperative vision (visual impairment score grade=2, 3, 4) with tumor size. The estimated area under the ROC curve was derived as 0.868 (95% CI=0.739 to 0.997, p-value <0.001). The best cut-off of tumor size was=2.2 cm based on the maximization of Youden index with a sensitivity=87.5% and specificity=83.3%. This cut-off was rounded to 2 for use in subsequent analyses. CI: confidence interval.

• 

  Fig. 3 Flowchart of patient enrollment.

• 

  Fig. 4 Dispersion of pre-operative (Pre-OP) and post-operative (Post-OP) visual impairment score (VIS) grade by pituitary adenoma size. Data were graphed as a bar as percentage of VIS. Difference between Pre-OP and Post-OP for a given size of pituitary adenoma was compared using Wilcoxon signed ranks test. Difference for pair-wise comparison among pituitary adenoma sizes was performed using Mann-Whitney U test for Pre-OP and Post-OP, respectively. *p<0.05, indicates significant difference between Pre-OP and Post-OP. †Significant difference compared with small macroadenoma for pair-wise comparison among pituitary adenoma sizes considering an adjusted significance level of 0.0167 (0.05/3). There was no significant difference compared with large macroadenoma.

• 

  Fig. 5 Shows pre-op and post-op VF of a 43-year-old female with a tumor 7.05 cm in size. Optic disc displacement in the sagittal view was 1.45 cm and in the coronal view 1.40 cm. A: The preoperative BCVA score was 57 (right eye: 0.05, left eye: 0.32) and the pre-op VF score was 22 (left homonymous hemianopsia). Therefore the total pre-op VIS was 79. B: The post-op BCVA score was 15 (right eye: 0.2, left eye: 1.0) and the post-op VF score was 22 (left homonymous hemianopsia). Therefore, the total post-op VIS was 37. VF: visual field, BCVA: best-corrected visual acuity, VIS: visual impairment score.

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