Original Article
Visual parameters in patients with pituitary adenorna before and after transsphenoidal surgery Mira Marcus, M D Susan Vitale, MHS Preston C. Calvert, M D Neil R. Miller, M D
Abstract Eighty-two patients with pituitary adenoma who underwent transsphenoidal surgery were examined before and after surgery. Nineteen patients had a normal preoperative neuro-ophthalmologicalexamination. All of these patients maintained normal visual parameters postoperatively. The remaining 63 patients had tumour-related loss of visual acuity, visual field, or both. These patients ranged in age from 18 to 78 years. Duration of symptoms ranged from one day to ten years, with a median of six months. Preoperative visual acuity was 6/12 or better in 72% of eyes, with 90% of patients having 6/12 or better in their better eye. Only 7% of eyes had a normal preoperative visual field. Both visual acuity and visual field improved postoperatively in the majority of eyes. In eyes that were examined within one week after surgery and subsequently, substantial improvement occurred within the first postoperative week, but further improvement continued over weeks to months postoperatively, with visual field taking longer to stabilise than visual acuity. Visual acuity at last examination was 6/12 or better in 87% of eyes, and visual field at last examination was normal in 50% of eyes. A total of 92% of patients had visual acuity of 6/12 or better
From the Wiltner Ophrhafmologicai Insrirure, rhe Johns Hopkins Medical Insrirurions, Baltimore, Maryland.
in their better eye, and 62% of patients had a normal visual field in their better eye. Visual acuity at last examination was correlated with both age and preoperative visual acuity. Last visual field also was correlated with both age and preoperative visual field. Patients with preoperative optic atrophy had a poorer visual prognosis than did patients with normal fundi.
Key words: Optic atrophy, pituitary adenoma, transsphenoidal surgery, visual acuity, visual field.
Most patients with pituitary adenomas are diagnosed when they develop symptoms or signs of endocrine dysfunction or after neuroimaging studies performed under circumstances unrelated to the tumour. Some patients however, develop visual disturbances either as the presenting manifestation or as an associated feature of a pituitary adenoma. Most of the latter are men and women with non-secreting adenomas, or men and postmenopausal women with prolactin-secreting adenomas.'.2 There is no standard method by which patients with visual loss caused by pituitary adenoma are evaluated. In addition, there are conflicting opinions as to what factors affect visual prognosis after t ~ e a t m e n t . We ~ - ~have performed a retrospective study of patients evaluated in the Neuro-Ophthalmology Unit of the Johns Hopkins Hospital and operated by the transsphenoidal
Reprinf reqricsrs: Dr N. Miller, Maumenee B-109, The Wilmer Institute, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, Maryland, USA. Visual prognosis of pituitary adenomas
111
technique during the last 12 years. The aims of this study were: to determine the preoperative and postoperative visual function of our patients; and to identify features that would enable us to predict the visual result of therapy.
Patients and methods The records of all patients with pituitary adenoma evaluated in the Neuro-Ophthalmology Unit and treated surgically by a member of the department of Neurosurgery at the Johns Hopkins Hospital from 1976 to 1987 were reviewed. During this period, 110 patients underwent surgery for pituitary adenoma. Twenty-eight of these patients underwent craniotomy either because the tumour was misdiagnosed as some other lesion (e.g., craniopharyngioma, meningioma) or because the neurosurgeon believed that this was the optimum approach for removal of the tumour. The remaining 82 patients underwent transsphenoidal surgery to remove the adenoma. In none of the 110 patients was the decision to perform either craniotomy or transsphenoidal surgery related to visual symptoms or signs. Nineteen of the 82 patients who underwent transsphenoidal surgery (23%) had normal visual function before and after surgery. T h e remaining 63 patients had visual dysfunction thought to be caused by the pituitary adenoma and are the subject of this report. Eight of the 63 patients (13%) with preoperative visual loss had received some type of treatment before undergoing transsphenoidal surgery. One of the eight patients had had previous transsphenoidal surgery, three had undergone previous craniotomy and radiation therapy, one had undergone two craniotomies followed by radiation therapy, one had undergone radiation therapy alone, and two had been treated with bromocriptine for more than one month but less than one year before surgery. All patients in this study underwent a complete preoperative examination in the Neuro-Ophthalmology Unit. Best-corrected visual acuity (VA) was tested by using projected Snellen letters for distance. A Jaeger card was used for assessing near VA. Colour vision was tested by using Hardy-RandRittler pseudoisochromatic plates. Results were expressed as the number of plates correctly identified. Ten plates were used. If a plate contained two figures, and the patient correctly identified only one of them, the patient was given credit for having identified half a plate. 112
Visual field (VF) examinations were performed in several ways. The confrontation technique described by Trobe et aLb was performed on five eyes of three patients, one of whom had such poor visual acuity that a field could not be performed reliably using either a Bjerrum screen or a Goldmann perimeter, and two of whom were too ill at the time of examination to undergo any other method of perimetry. In the remaining 60 patients, both central and peripheral fields were tested by using a Goldmann perimeter. All patients were tested with V14e, 1/4e, and I/2e targets. A Bjerrum (tangent) screen was also used to test the central field. The patient was situated 2 metres from the screen, and both white and red test objects measuring 6 mm, 9 mm, and/or 18 mm were used. Most patients who had defects when tested with the Goldmann perimeter also had defects when tested with the tangent screen. In one eye of one patient, a small temporal scotoma to a red test object identified when using the tangent screen was not detected during achromatic testing with the Goldmann perimeter, and in both eyes of another patient, temporal desaturation to a red test object was also unassociated with any field defect detected with the Goldmann perimeter. Both patients were considered to have ‘full’ visual fields for statistical purposes, although in both patients, the defects to red resolved after surgery. Visual field loss was therefore classified in all but five eyes according to its characteristics by using the Goldmann perimeter. Absolute field loss was defined as a defect to a V14e stimulus or, in five eyes of three patients, as an area with less than hand motion vision by confrontation technique. Non-absolute VF loss was said to be present when a defect was detected to the smallest or dimmest target identified by the patient but not necessarily to a larger target. T o permit quantitative analysis of both absolute and non-absolute visual field loss, we used the method described by Findlay et a1.’ None of the patients in this study were evaluated using automated perimetry. Pupil size and reactivity were assessed by using the brightest possible light from an indirect ophthalmoscope. The presence of a relative afferent pupillary defect was noted and graded from 1 to 4. Ophthalmoscopic examination was performed with a fully charged direct ophthalmoscope. The appearance of the optic disc and retinal nerve fibre layer were defined as normal or atrophic. No patient had papilloedema. Slit lamp biomicroscopy, applanation tonometry, and assessment of extraocular motility and
+
+
Australian and New Zealand Journal of Ophthalmology 1991; 19(2)
Table 1. Patient Characteristics Number (Yo) Age (years)
18 to 40 41 to 60 61 to 78 Sex Male Female Duration of symptoms (months) Less than 6 6 to 12 12 to 36 36 to 120 Unknown None Major Presenting Symptom Visual Endocrine Routine exam Apoplexy Recurrence Headache Diplopia
18 (29) 25 (40) 20 (32) 39 (62) 24 (38) 28 (44) 13 (21) 8 (13) 8 (13) 1 (1) 5 (8) 34 (54) 12 (19) 5 (8) 4 (6) 3 (5) 3 (5) 2 (3)
alignment were performed on every patient. Patients in whom abnormalities of extraocular movements were identified underwent a complete orthoptics examination. In addition to undergoing a complete neuroophthalmologic examination before transsphenoidal surgery, all 63 patients were examined one or more times after surgery. Thus, a total of 126 eyes were evaluated preoperatively and at some time postoperatively. Within one week after surgery, 122 eyes of 6 1 patients (97%) were examined. Subsequent examinations were performed on 106 eyes of 53 patients (84?70).Of the 63 patients in the study, 11 (17%) had their last postoperative examination within one month of surgery, 15 patients (24%) had their last examination one to six months after surgery, and the remaining 37 patients (59%) had their last examination from six months to twelve years after surgery. The median follow-up for all patients was ten months. Of the 63 patients in this study, 51 (81%) underwent postoperative radiation therapy. Of the 12 patients who receive no postoperative radiation, five had previously been radiated and could not be given further radiation. Six other patients were treated postoperatively with bromocriptine, and one had no further treatment during the follow-up period. Statistical methods used to analyse data included the chi-square test for comparing proportions and the t-test for correlation coefficients. For some statistical computations involving VA, we used tables of 70VA loss from the Physicians’ Desk Visual prognosis of pituitary adenomas
Table 2. Preoperative and final visual acuity (n = 126) -
Number of eyes (Yo) Visual acuity
Preoperative
Final
6/12 or better 6/15 to 6/60 6/60 or worse
91 (72) 23 (18) 12 (10)
110 (87) 9 (7) 7 (6)
Reference (PDR) for Ophthalmology8 or the logarithmic value of VA.9
Results General characteristics The ages of the 63 patients in this study ranged between 18 and 78 years. There were 24 women and 39 men. The ratio of men to women increased with increasing age, from about 1: 1 under 40 years of age to 2:1 over 40 years of age. The duration of symptoms before operation varied from one day to ten years, with a median duration of six months. The shortest time was in patients with pituitary apoplexy, and the longest time was in patients with acromegaly or with amenorrhoea and galactorrhoea. The presenting symptom was visual (VA, VF or both) in 34 patients and endocrinologic in 12. Four patients presented with pituitary apoplexy (one of whom had a known but previously asymptomatic tumour). Three patients were investigated because of headache. Two patients had diplopia from a unilateral oculomotor nerve paresis. Four patients without visual or endocrine complaints were found to harbour a pituitary adenoma after a routine ocular examination detected unexplained visual loss. One patient was found to have a pituitary adenoma after a skull x-ray performed for an unrelated problem showed an enlarged sella turcica. Three patients had recurrent tumours on regular follow-up examination (Table 1). Visual Findings Visual Acuity Preoperative visual acuity was 616 or better in 42 of 126 eyes (33%). Of the remaining 84 eyes, 49 had VA of 617.5 to 6/12, and only 12 eyes (10%) had preoperative VA worse than 6/60 (Table 2). Ninety per cent of patients had 6/12 or better vision in their better eye, whereas only one patient had 6/60 or worse in the better eye (Table 3). Younger patients were significantly more likely 113
/
Table 3. Preoperative a n d final visual acuity in better eye (n = 63)
126 Eyes
Preoperative
616
42 Eves
6 Eyes*
36 Eyes
616\
Number of Patients (To) 84 Eves
43 Eyes
41 Eyes
Fig. 1. -Prognosis for visual acuity. (*All had non-neurologic visual loss.)
to have preoperative VA of 6/6 or better (p = 0.001). VA at last postoperative examination was 6/6 or better in 79 of 126 eyes (63%), and 6/12 or better in 110 eyes (87%). Seventy-six per cent of patients had last postoperative VA of 6/6 or better in their better eye, 92% of patients had postoperative VA of 6/12 or better in their better eye, and only 2% of patients had 6/60 or worse in their better eye after surgery. We next examined the differences in postoperative VA between those with good (6/6 or better) and those with poor (less than 6/6 preoperative VA (Figure 1). Of the 42 eyes (33%) with preoperative VA of 6/6 or better, 36 (86%) had postoperative VA of 616 or better, four had 617.5, one had 6/9, and one had 6/12. In all six eyes with postoperative VA less than 6/6, both colour vision and VF were improved from preoperative values, suggesting that the decrease in VA after surgery was not neurologic. We believe that no eye that had preoperative VA of 6/6 or better experienced neurologic visual loss after surgery. Of the 84 eyes with preoperative VA less than 6/6, 43 (51%) had postoperative VA of 6/6, and 19 improved after surgery but not to 616. To assess the potential for further improvement after one week postoperatively, the 65 eyes with preoperative VA less than 616 that were evaluated both one week after surgery and at a subsequent time, were evaluated in detail (Table 4). A total of 40 of these 65 eyes (62%) improved within one week after surgery (21 improving to 6/6), 20 (31%) stayed the same during this time, and only 5 (8%) worsened. Of the 19 eyes that improved to less than 6/6 within one week after surgery, 11 nevertheless had VA of 6/6 at final examination. Of the 20 eyes that remained unchanged over the week following 114
Visual Acuity
Preoperative
Final
6/12 or better 6/15 to 6/60 6/60 or worse
57 (90) 5 (8) 1 (2)
58 (92) 4 (6) 1 (2)
surgery, 10 (50%) eventually improved to some extent, with six improving to 6/6 or better by final examination. Eyes that worsened within the week after surgery still had the potential to improve over time. Of the five eyes with preoperative VA less than 6/6 that worsened within the first week after surgery, one eye eventually improved to 6/6, one eye improved to the preoperative level of vision, and one eye improved but not to preoperative VA. Overall, 35 of the 65 eyes (54%) eventually had visual acuity of 616 or better. VA at last examination significantly correlated with age (p = 0.003), with older patients tending towards worse final VA. There was, however, no significant correlation between increasing age and longer duration of symptoms. Neither the mean nor
Table 4. Visual prognosis for 65 eyes with preoperative VA less than 6/6 1 Week Postoperatively 21 eyes (32%) improved to 6/6 or better
~~
Final Exam 17 eyes 6/6 or better 3 eyes better than preoperative level but not 6/6 1 eye worse than preoperative level
~
19 eyes (29Yo) improved but not to 616
11 eyes improved further to 6/6 4 eyes improved further but not to 616 3 eyes remained unchanged 1 eye worse than at 1 week but better than preoperative level
~
20 eyes (31%) remained unchanged from preop
6 eyes improved to 6/6 or better 4 eyes improved but not to 6/6 7 eyes remained unchanged 3 eyes worsened
5 eyes (870) were worse than PreoP
1 eye improved to 6/6 I eye improved but not back to preoperative level 1 eye improved to preoperative level 2 eyes remained unchanged
Australian and New Zealand Journal of Ophthalmology 1991; 19(2)
the median duration of symptoms were significantly correlated with increasing age (Table 5). T o determine whether age itself was a factor in the poor postoperative results of the oldest age group, or if postoperative results were simply related to the level of preoperative VA (which was best in the youngest age group - see above), we determined for specific age groups (18 to 40,41 to 60, and 61 to 78) years the probability of a patient achieving final VA of 6/12 or better given the preoperative VA (either 6/12 or better, or worse than 6/12). Patients in all age groups who had preoperative VA of 6/12 or better had an excellent chance of achieving last VA of 6/12 or better (100% chance in the 18 to 40 and 41 to 60 year age groups and 94% in the 61 to 78 year age group). Therefore, age did not affect the chance of a good visual outcome for those patients with good preoperative VA. For the few patients with preoperative visual acuity worse than 6/12, ‘good‘ postoperative VA was possible in all age groups, although the small numbers do not allow a conclusive statement from a statistical point of view. Patients with preoperative VA worse than 616 had a good chance of attaining postoperative VA of 6/6 or better in all age groups (33%, 7770, and 50% for the 18 to 40, 41 to 60, and 61 to 78 groups, respectively) and there were no significant differences between these probabilities for the age groups. We conclude that there is no evidence that age affects the chance of a good visual outcome, over and above the fact that older patients tend to have worse preoperative VA and are therefore less likely to have a good postoperative visual outcome as are most patients with poor preoperative VA.
Table 5. Age (years)
Mean Duration (months)
18 to 40 41 to 60 61 to 78
23.0 15.5 17.8
8 12 6
Preoperative and final visual fields Preoperative
Field loss
Median Duration (months)
four (3%) had general field constriction, and seven (6%) had hemianopic loss of both temporal and nasal field that affected more than half of the total field. Thus, all but four eyes with abnormal visual fields had some defect in the temporal hemifield. One week postoperatively, only 73 of 122 eyes examined (60%) had some field loss, and only 35 of these eyes (29%) had absolute field loss. At last examination, 63 of 126 eyes (50%) had some visual field defect; only 23% still had absolute VF loss (Table 6). Among eyes that were examined both one week postoperatively and subsequently, the majority of visual field improvement occurred within the first week after surgery, but further improvement also occurred later (Tables 7 and 8). Age did not correlate with greater preoperative VF loss, but it did correlate with both absolute and any postoperative VF loss (p = 0.08 and 0.06, respectively). Duration of symptoms was not correlated with preoperative or postoperative VF loss. In general, there was significant correlation between VA and both absolute and any VF loss at both preoperative and last examinations (p
Visual parameters in patients with pituitary adenorna before and after transsphenoidal surgery Mira Marcus, M D Susan Vitale, MHS Preston C. Calvert, M D Neil R. Miller, M D
Abstract Eighty-two patients with pituitary adenoma who underwent transsphenoidal surgery were examined before and after surgery. Nineteen patients had a normal preoperative neuro-ophthalmologicalexamination. All of these patients maintained normal visual parameters postoperatively. The remaining 63 patients had tumour-related loss of visual acuity, visual field, or both. These patients ranged in age from 18 to 78 years. Duration of symptoms ranged from one day to ten years, with a median of six months. Preoperative visual acuity was 6/12 or better in 72% of eyes, with 90% of patients having 6/12 or better in their better eye. Only 7% of eyes had a normal preoperative visual field. Both visual acuity and visual field improved postoperatively in the majority of eyes. In eyes that were examined within one week after surgery and subsequently, substantial improvement occurred within the first postoperative week, but further improvement continued over weeks to months postoperatively, with visual field taking longer to stabilise than visual acuity. Visual acuity at last examination was 6/12 or better in 87% of eyes, and visual field at last examination was normal in 50% of eyes. A total of 92% of patients had visual acuity of 6/12 or better
From the Wiltner Ophrhafmologicai Insrirure, rhe Johns Hopkins Medical Insrirurions, Baltimore, Maryland.
in their better eye, and 62% of patients had a normal visual field in their better eye. Visual acuity at last examination was correlated with both age and preoperative visual acuity. Last visual field also was correlated with both age and preoperative visual field. Patients with preoperative optic atrophy had a poorer visual prognosis than did patients with normal fundi.
Key words: Optic atrophy, pituitary adenoma, transsphenoidal surgery, visual acuity, visual field.
Most patients with pituitary adenomas are diagnosed when they develop symptoms or signs of endocrine dysfunction or after neuroimaging studies performed under circumstances unrelated to the tumour. Some patients however, develop visual disturbances either as the presenting manifestation or as an associated feature of a pituitary adenoma. Most of the latter are men and women with non-secreting adenomas, or men and postmenopausal women with prolactin-secreting adenomas.'.2 There is no standard method by which patients with visual loss caused by pituitary adenoma are evaluated. In addition, there are conflicting opinions as to what factors affect visual prognosis after t ~ e a t m e n t . We ~ - ~have performed a retrospective study of patients evaluated in the Neuro-Ophthalmology Unit of the Johns Hopkins Hospital and operated by the transsphenoidal
Reprinf reqricsrs: Dr N. Miller, Maumenee B-109, The Wilmer Institute, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, Maryland, USA. Visual prognosis of pituitary adenomas
111
technique during the last 12 years. The aims of this study were: to determine the preoperative and postoperative visual function of our patients; and to identify features that would enable us to predict the visual result of therapy.
Patients and methods The records of all patients with pituitary adenoma evaluated in the Neuro-Ophthalmology Unit and treated surgically by a member of the department of Neurosurgery at the Johns Hopkins Hospital from 1976 to 1987 were reviewed. During this period, 110 patients underwent surgery for pituitary adenoma. Twenty-eight of these patients underwent craniotomy either because the tumour was misdiagnosed as some other lesion (e.g., craniopharyngioma, meningioma) or because the neurosurgeon believed that this was the optimum approach for removal of the tumour. The remaining 82 patients underwent transsphenoidal surgery to remove the adenoma. In none of the 110 patients was the decision to perform either craniotomy or transsphenoidal surgery related to visual symptoms or signs. Nineteen of the 82 patients who underwent transsphenoidal surgery (23%) had normal visual function before and after surgery. T h e remaining 63 patients had visual dysfunction thought to be caused by the pituitary adenoma and are the subject of this report. Eight of the 63 patients (13%) with preoperative visual loss had received some type of treatment before undergoing transsphenoidal surgery. One of the eight patients had had previous transsphenoidal surgery, three had undergone previous craniotomy and radiation therapy, one had undergone two craniotomies followed by radiation therapy, one had undergone radiation therapy alone, and two had been treated with bromocriptine for more than one month but less than one year before surgery. All patients in this study underwent a complete preoperative examination in the Neuro-Ophthalmology Unit. Best-corrected visual acuity (VA) was tested by using projected Snellen letters for distance. A Jaeger card was used for assessing near VA. Colour vision was tested by using Hardy-RandRittler pseudoisochromatic plates. Results were expressed as the number of plates correctly identified. Ten plates were used. If a plate contained two figures, and the patient correctly identified only one of them, the patient was given credit for having identified half a plate. 112
Visual field (VF) examinations were performed in several ways. The confrontation technique described by Trobe et aLb was performed on five eyes of three patients, one of whom had such poor visual acuity that a field could not be performed reliably using either a Bjerrum screen or a Goldmann perimeter, and two of whom were too ill at the time of examination to undergo any other method of perimetry. In the remaining 60 patients, both central and peripheral fields were tested by using a Goldmann perimeter. All patients were tested with V14e, 1/4e, and I/2e targets. A Bjerrum (tangent) screen was also used to test the central field. The patient was situated 2 metres from the screen, and both white and red test objects measuring 6 mm, 9 mm, and/or 18 mm were used. Most patients who had defects when tested with the Goldmann perimeter also had defects when tested with the tangent screen. In one eye of one patient, a small temporal scotoma to a red test object identified when using the tangent screen was not detected during achromatic testing with the Goldmann perimeter, and in both eyes of another patient, temporal desaturation to a red test object was also unassociated with any field defect detected with the Goldmann perimeter. Both patients were considered to have ‘full’ visual fields for statistical purposes, although in both patients, the defects to red resolved after surgery. Visual field loss was therefore classified in all but five eyes according to its characteristics by using the Goldmann perimeter. Absolute field loss was defined as a defect to a V14e stimulus or, in five eyes of three patients, as an area with less than hand motion vision by confrontation technique. Non-absolute VF loss was said to be present when a defect was detected to the smallest or dimmest target identified by the patient but not necessarily to a larger target. T o permit quantitative analysis of both absolute and non-absolute visual field loss, we used the method described by Findlay et a1.’ None of the patients in this study were evaluated using automated perimetry. Pupil size and reactivity were assessed by using the brightest possible light from an indirect ophthalmoscope. The presence of a relative afferent pupillary defect was noted and graded from 1 to 4. Ophthalmoscopic examination was performed with a fully charged direct ophthalmoscope. The appearance of the optic disc and retinal nerve fibre layer were defined as normal or atrophic. No patient had papilloedema. Slit lamp biomicroscopy, applanation tonometry, and assessment of extraocular motility and
+
+
Australian and New Zealand Journal of Ophthalmology 1991; 19(2)
Table 1. Patient Characteristics Number (Yo) Age (years)
18 to 40 41 to 60 61 to 78 Sex Male Female Duration of symptoms (months) Less than 6 6 to 12 12 to 36 36 to 120 Unknown None Major Presenting Symptom Visual Endocrine Routine exam Apoplexy Recurrence Headache Diplopia
18 (29) 25 (40) 20 (32) 39 (62) 24 (38) 28 (44) 13 (21) 8 (13) 8 (13) 1 (1) 5 (8) 34 (54) 12 (19) 5 (8) 4 (6) 3 (5) 3 (5) 2 (3)
alignment were performed on every patient. Patients in whom abnormalities of extraocular movements were identified underwent a complete orthoptics examination. In addition to undergoing a complete neuroophthalmologic examination before transsphenoidal surgery, all 63 patients were examined one or more times after surgery. Thus, a total of 126 eyes were evaluated preoperatively and at some time postoperatively. Within one week after surgery, 122 eyes of 6 1 patients (97%) were examined. Subsequent examinations were performed on 106 eyes of 53 patients (84?70).Of the 63 patients in the study, 11 (17%) had their last postoperative examination within one month of surgery, 15 patients (24%) had their last examination one to six months after surgery, and the remaining 37 patients (59%) had their last examination from six months to twelve years after surgery. The median follow-up for all patients was ten months. Of the 63 patients in this study, 51 (81%) underwent postoperative radiation therapy. Of the 12 patients who receive no postoperative radiation, five had previously been radiated and could not be given further radiation. Six other patients were treated postoperatively with bromocriptine, and one had no further treatment during the follow-up period. Statistical methods used to analyse data included the chi-square test for comparing proportions and the t-test for correlation coefficients. For some statistical computations involving VA, we used tables of 70VA loss from the Physicians’ Desk Visual prognosis of pituitary adenomas
Table 2. Preoperative and final visual acuity (n = 126) -
Number of eyes (Yo) Visual acuity
Preoperative
Final
6/12 or better 6/15 to 6/60 6/60 or worse
91 (72) 23 (18) 12 (10)
110 (87) 9 (7) 7 (6)
Reference (PDR) for Ophthalmology8 or the logarithmic value of VA.9
Results General characteristics The ages of the 63 patients in this study ranged between 18 and 78 years. There were 24 women and 39 men. The ratio of men to women increased with increasing age, from about 1: 1 under 40 years of age to 2:1 over 40 years of age. The duration of symptoms before operation varied from one day to ten years, with a median duration of six months. The shortest time was in patients with pituitary apoplexy, and the longest time was in patients with acromegaly or with amenorrhoea and galactorrhoea. The presenting symptom was visual (VA, VF or both) in 34 patients and endocrinologic in 12. Four patients presented with pituitary apoplexy (one of whom had a known but previously asymptomatic tumour). Three patients were investigated because of headache. Two patients had diplopia from a unilateral oculomotor nerve paresis. Four patients without visual or endocrine complaints were found to harbour a pituitary adenoma after a routine ocular examination detected unexplained visual loss. One patient was found to have a pituitary adenoma after a skull x-ray performed for an unrelated problem showed an enlarged sella turcica. Three patients had recurrent tumours on regular follow-up examination (Table 1). Visual Findings Visual Acuity Preoperative visual acuity was 616 or better in 42 of 126 eyes (33%). Of the remaining 84 eyes, 49 had VA of 617.5 to 6/12, and only 12 eyes (10%) had preoperative VA worse than 6/60 (Table 2). Ninety per cent of patients had 6/12 or better vision in their better eye, whereas only one patient had 6/60 or worse in the better eye (Table 3). Younger patients were significantly more likely 113
/
Table 3. Preoperative a n d final visual acuity in better eye (n = 63)
126 Eyes
Preoperative
616
42 Eves
6 Eyes*
36 Eyes
616\
Number of Patients (To) 84 Eves
43 Eyes
41 Eyes
Fig. 1. -Prognosis for visual acuity. (*All had non-neurologic visual loss.)
to have preoperative VA of 6/6 or better (p = 0.001). VA at last postoperative examination was 6/6 or better in 79 of 126 eyes (63%), and 6/12 or better in 110 eyes (87%). Seventy-six per cent of patients had last postoperative VA of 6/6 or better in their better eye, 92% of patients had postoperative VA of 6/12 or better in their better eye, and only 2% of patients had 6/60 or worse in their better eye after surgery. We next examined the differences in postoperative VA between those with good (6/6 or better) and those with poor (less than 6/6 preoperative VA (Figure 1). Of the 42 eyes (33%) with preoperative VA of 6/6 or better, 36 (86%) had postoperative VA of 616 or better, four had 617.5, one had 6/9, and one had 6/12. In all six eyes with postoperative VA less than 6/6, both colour vision and VF were improved from preoperative values, suggesting that the decrease in VA after surgery was not neurologic. We believe that no eye that had preoperative VA of 6/6 or better experienced neurologic visual loss after surgery. Of the 84 eyes with preoperative VA less than 6/6, 43 (51%) had postoperative VA of 6/6, and 19 improved after surgery but not to 616. To assess the potential for further improvement after one week postoperatively, the 65 eyes with preoperative VA less than 616 that were evaluated both one week after surgery and at a subsequent time, were evaluated in detail (Table 4). A total of 40 of these 65 eyes (62%) improved within one week after surgery (21 improving to 6/6), 20 (31%) stayed the same during this time, and only 5 (8%) worsened. Of the 19 eyes that improved to less than 6/6 within one week after surgery, 11 nevertheless had VA of 6/6 at final examination. Of the 20 eyes that remained unchanged over the week following 114
Visual Acuity
Preoperative
Final
6/12 or better 6/15 to 6/60 6/60 or worse
57 (90) 5 (8) 1 (2)
58 (92) 4 (6) 1 (2)
surgery, 10 (50%) eventually improved to some extent, with six improving to 6/6 or better by final examination. Eyes that worsened within the week after surgery still had the potential to improve over time. Of the five eyes with preoperative VA less than 6/6 that worsened within the first week after surgery, one eye eventually improved to 6/6, one eye improved to the preoperative level of vision, and one eye improved but not to preoperative VA. Overall, 35 of the 65 eyes (54%) eventually had visual acuity of 616 or better. VA at last examination significantly correlated with age (p = 0.003), with older patients tending towards worse final VA. There was, however, no significant correlation between increasing age and longer duration of symptoms. Neither the mean nor
Table 4. Visual prognosis for 65 eyes with preoperative VA less than 6/6 1 Week Postoperatively 21 eyes (32%) improved to 6/6 or better
~~
Final Exam 17 eyes 6/6 or better 3 eyes better than preoperative level but not 6/6 1 eye worse than preoperative level
~
19 eyes (29Yo) improved but not to 616
11 eyes improved further to 6/6 4 eyes improved further but not to 616 3 eyes remained unchanged 1 eye worse than at 1 week but better than preoperative level
~
20 eyes (31%) remained unchanged from preop
6 eyes improved to 6/6 or better 4 eyes improved but not to 6/6 7 eyes remained unchanged 3 eyes worsened
5 eyes (870) were worse than PreoP
1 eye improved to 6/6 I eye improved but not back to preoperative level 1 eye improved to preoperative level 2 eyes remained unchanged
Australian and New Zealand Journal of Ophthalmology 1991; 19(2)
the median duration of symptoms were significantly correlated with increasing age (Table 5). T o determine whether age itself was a factor in the poor postoperative results of the oldest age group, or if postoperative results were simply related to the level of preoperative VA (which was best in the youngest age group - see above), we determined for specific age groups (18 to 40,41 to 60, and 61 to 78) years the probability of a patient achieving final VA of 6/12 or better given the preoperative VA (either 6/12 or better, or worse than 6/12). Patients in all age groups who had preoperative VA of 6/12 or better had an excellent chance of achieving last VA of 6/12 or better (100% chance in the 18 to 40 and 41 to 60 year age groups and 94% in the 61 to 78 year age group). Therefore, age did not affect the chance of a good visual outcome for those patients with good preoperative VA. For the few patients with preoperative visual acuity worse than 6/12, ‘good‘ postoperative VA was possible in all age groups, although the small numbers do not allow a conclusive statement from a statistical point of view. Patients with preoperative VA worse than 616 had a good chance of attaining postoperative VA of 6/6 or better in all age groups (33%, 7770, and 50% for the 18 to 40, 41 to 60, and 61 to 78 groups, respectively) and there were no significant differences between these probabilities for the age groups. We conclude that there is no evidence that age affects the chance of a good visual outcome, over and above the fact that older patients tend to have worse preoperative VA and are therefore less likely to have a good postoperative visual outcome as are most patients with poor preoperative VA.
Table 5. Age (years)
Mean Duration (months)
18 to 40 41 to 60 61 to 78
23.0 15.5 17.8
8 12 6
Preoperative and final visual fields Preoperative
Field loss
Median Duration (months)
four (3%) had general field constriction, and seven (6%) had hemianopic loss of both temporal and nasal field that affected more than half of the total field. Thus, all but four eyes with abnormal visual fields had some defect in the temporal hemifield. One week postoperatively, only 73 of 122 eyes examined (60%) had some field loss, and only 35 of these eyes (29%) had absolute field loss. At last examination, 63 of 126 eyes (50%) had some visual field defect; only 23% still had absolute VF loss (Table 6). Among eyes that were examined both one week postoperatively and subsequently, the majority of visual field improvement occurred within the first week after surgery, but further improvement also occurred later (Tables 7 and 8). Age did not correlate with greater preoperative VF loss, but it did correlate with both absolute and any postoperative VF loss (p = 0.08 and 0.06, respectively). Duration of symptoms was not correlated with preoperative or postoperative VF loss. In general, there was significant correlation between VA and both absolute and any VF loss at both preoperative and last examinations (p
