Basic and elaborated description of Neuro-ophthalmic evaluation

1. Ophthalmological Evaluation in
Sellar Suprasellar Tumors
Dr Fakir Mohan Sahu
MCh Senior Resident
AIIMS Bhubaneswar
18/07/2020

2. Learning Objectives
• Sella, Suprasellar and Chiasmal anatomy
• Visual Pathway and Organisation of Nerve fibres
• Tumours of sellar suprasellar region
• Basic and Morden Neuro-ophthalmological examination
• Approach to different sellar and suprasellar tumor
• Ophthalmological outcome following surgery

3. Anatomy of sellar and parasellar Region
SELLA

7. Relationships of the optic nerves and
optic chiasm to the sellar structures
Third ventricle (III).
C-anterior clinoid
D-dorsum sellae.
Pituitary gland
Pear shaped gland
Attached with infundibulum
Ant and post lobe
The diaphragma is thinnest centrally
around the infundibulum and increases
peripherally
The thickness and the degree of incompetence of the diaphragma sella may
determine the ease and rapidity of suprasellar growth of pituitary tumors

8. Chiasmal Position
Variation in relative position contributes to
clinical variation in the presentation of neuro-
ophthalmological chiasmal syndromes

9. Normal Visual Pathway

10. Organisation of Retinal Nerve Fibre layer(RNFL)
Optic Nerve Optic TractOptic Chiasma
• Optic chiasm decussation
Inferior nasal fibers - anteroinferior
Superior nasal fibers - posterosuperior

11. Lesions and VF defect

12. Common Sellar Suprasellar tumour
• Pituitary tumours / Apoplexy
• Craniopharyngioma
• Meningioma (Tuberculum sella, Diaphragm sella, Sphenoid wing, Palanum sphenoidale)
• Chiasmatic Glioma / Optic nerve glioma
• Dermoid/Epidermoid
• Germinoma
• Schwannoma
• Chondromas
• Metastasis
• Rathke’s cleft cyst
• Empty Sella Turcica
• 3rd Ventricular tumour extension

13. Effect of Tumours on vision
Direct effects:
Direct compression.
• Optic chiasm (Normal variant)
• Optic nerve post-fixed chiasm
• Optic tracts  pre-fixed chiasm
• 3rd , 4th, 6th nerves with CS extension
• Third ventricle leading to hydrocephalus
Indirect effects:
• Papilloedema
• Impact of tumour resection
• Post-radiation neuropathy
• Toxic effects due to chemotherapy
• Metastatic lesions to retina or infiltration of optic nerve
• Haematological effects like ischemia, venous engorgement

14. INVESTIGATION PROTOCOL
• History and physical examination
• Neuro-ophthalmology:
 Visual acuity
Colour vision
 Ophthalmoscopy
 Visual fields
 Pupils
 Extraocular movements
• Neuro-endocrine: Hormone levels- basal hormone and dynamic testing
• Radiology (a) X-Rays
(b) MRI
(c) NCCT/CECT
(d)PET/DSA
• Routine blood investigation

15. Neuro-ophthalmics of Sellar Suprasellar tumour
Colour Vision
Loss of colour vision precedes other visual deficits
Red perception is lost first described as red desaturation
Ishihara/hardy ritter rand charts used

16. Neuro-ophthalmics of Sellar Suprasellar tumour
Pituitary adenoma  Primary optic atrophy
primary secondary
Colour of disc white grey
Border of disc Sharp Blurred
Arteries and veins Normal or reduced Arteries thin, veins dilated
Distribution May affect one sector Entire disc affected
Causes Optic nerve/retinal damage Papillitis/papilledema
Lamina cribrosa visible Not visible

17. Normal Field of vision
• 3D area when fixating at a central target.
Visual fields
90 -100 deg temporally
60 deg nasally
50-60 deg superiorly
60-75 deg inferiorly
With binocular vision , VF of both eyes overlap (60 degrees )

18. Goldman’s Perimeter
Visual fields are analyzed by
 Confrontation method
 Goldman's perimeter
 Humphrey’s Automated perimeter

20. Anterior optic chiasmal syndrome
Automated static perimetry
 From Damage to the Anterior Angle of the Optic
Chiasm
 Post –fixed chiasm
 Tumour compressing where optic nerve and the
chiasm
 “Junctional scotoma” C/L eye and I/L temporal
hemianopia
 Asymptomatic scotoma in the superior temporal field of
the opposite eye (Wilbrand’s knee)

21. Central chiasm syndrome
 Bitemporal defect (quadrantic or hemianopic)
(Infiltrating tumors, such as gliomas, germ cell tumors, and
lymphomas,
 In most cases, visual acuity is normal.
 Suprasellar, infrachiasmatic lesion
(Pituitaryadenoma)
 Compresses the chiasm from below
 Defects are typically superior
 Bitemporal field defects that are denser below
 Suprasellar, suprachiasmatic lesions
(Meningiomas, Craniopharyngiomas)
Bitemporal hemianopia
frequently beginning in the inferior quadrants
 Papilledema suprasellar, supra-chiasmal lesions more
infra-chiasmal lesions

22. Optic Chiasmal Syndrome
Disturbance of depth perception
 Completely blind triangular area of field with its apex
at fixation  Convergence of the two blind temporal
hemifields
 The image of an object posterior to fixation falls on
blind nasal retinas and thus disappears.
 Difficulty with near tasks
(threading needles, sewing)

23. Retro-chiasmal syndrome
Posterior lesion  optic tract
Incongruous Homonymous Hemianopia
Posterior lesionCompressing macular fibers
Bitemporal central scotoma

24. Visual Field Defects Caused by Lesion extension
• Optic nerve or the optic tract optic chiasm: the blind eye usually is on the side of the lesion.
Right optic nerve lesion: blind RE defect temporal field LE
Right optic tract lesion : Lt. Homonymous hemianopia  blindness or near-blindness RE
• Optic chiasm optic nerve or the optic tract:
Blind (or near-blind) eye is always on the side of the extension of the lesion.
Optic chiasm- Bitemporal hemianopia Rt optic nerve leads to RE blind
Rt optic tract, blindness or near-blindness RE.

25. Radiology
• X- Rays:Lateral & PA Skull + Lateral Sella turcica
Alignment of posterior clinoid processes
Widening of sella
Destruction of sellar floor
Relation of median sphenoidal septum
Aeration of sphenoid sinus

26. Imaging

28. Pituitary Macroadenoma

29. Modified Hardy Wilson Classification
Type A: Tumor bulges into the
chiasmatic cistern
Type B: Tumor reaches the floor of the
3rd ventricle
Type C: Tumor is more voluminous
with extension into the 3rd ventricle up
to the foramen of Monro
Type D: Tumor extends into temporal
or frontal fossa
TYPE E : Extradural spread (
extension into or out of the cavenous
sinus)
Grade 0 : Intrapituitary microadenoma with normal sellar floor
Grade I : Normal-sized sella with asymmetric floor
Grade II : Enlarged sella with an intact floor
Grade III : Localized erosion of sellar floor
Grade IV : Diffuse destruction of floor
Microadenomas – Grades 0 and I
Macroadenomas – Grades II to IV
Size and invasiveness

30. Craniopharyngioma

31. Meningioma
Tuberculum sella / Sphenoid wing
Foster Kennedy syndrome
 Optic Atrophy I/L eye
Papilledema in C/L eye
Central scotoma in I/L eye
Anosmia

33. Pituitary Apoplexy

34. Pituitary Microadenoma

35. Cushing’s disease
• Microadenoma/normal
• No compression effect
• Raised intraocular pressure and
Exophthalmos
(seen in up to 1/3rd patients in Cushing's original series)
• Cataracts complication of long term
corticosteroid therapy.
• Central serous chorioretinopathy
Dynamic scan showing delayed contrast uptake by adenoma

36. Cavernous sinus compression
• CN III, CN IV and CN VI paresis together with neuralgic pain
disturbances over the region (V1 ophthalmic)
• Mild exophthalmos, conjunctival and lid edema.
(Impaired orbital outflow)
• Lesion of the ICA sympathetic: Horner’s syndrome
(ptosis, miosis, and enophthalmos)

37.  Three lines are drawn between the supraclinoid ICA and
intracavernous ICA on coronal MRI imaging.
Medial tangent
Intercarotid line
Lateral tangent
 These lines are used to define 4 grades of tumor invasion:
Grade 0 = medial to medial tangent
Grade 1 = space between the medial tangent and the intercarotid line
Grade 2 = space between the intercarotid line and the lateral tangent
Grade 3 = tumor extends lateral to the lateral tangent
3A = superior cavernous sinus compartment
3B = inferior cavernous sinus compartment
Grade 4 = complete encasement of intracavernous ICA

38. Morden Neuro-ophthalmology
• Optic Coherence Tomography (OCT)
RNFL & GCL
Peripapillary RNFL thinning precedes visual field defects.
Detecting subclinical neuro-ophthalmological signs of
Chiasmal syndrome
• Visual Evoked Potentials
Evoked electro physiological potential extracted using signal from EEG activity recorded at the scalp.
Provides diagnostic information regarding the functional integrity of visual system.
Measures the time taken for visual stimuli to travel from eye to occipital cortex.
Particularly useful in infants

39. Surgical approach
Transcranial approach
• Intradural
Pre-chiasmal: Bifrontal, Pterional, Subfrontal
Retro-chiasmal: Interhemispheric
• Extradural- Orbito-zygomatic
Extracranial approach
• Endoscopic Trans-sphenoidal
• Endoscopic Trans nasal
Endoscopic Trans-ventricular approach
Lamina terminalis corridor

41. Conclusion
• Neuro-ophthalmological evaluation:
Aids in diagnosis of underlying tumour
 Allow predicting postoperative visual function
Medical clinical history and Neuro-endocrinological exam.
Early treatment leads to better ophthalmological outcome
Protects the patients
and the surgeon…………..

42. Thank You