The Radiologic Characteristics and Retinal Thickness Are Correlated With Visual Field Defect in Patients With a Pituitary Mass

Investigation of visual field defects (VFDs) is important to decide the treatment and to predict the prognosis in patients with a pituitary mass. The aim of this study was to evaluate the correlation among 2 diagnostic modalities-MRI and optical coherence tomography (OCT)-and VFDs.

Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD The Radiologic Characteristics and Retinal Thickness Are Correlated With Visual Field Defect in Patients With a Pituitary Mass Hiebum Suh, MD, Heeyoung Choi, MD, PhD, Hyeshin Jeon, MD Background: Investigation of visual field defects (VFDs) is important to decide the treatment and to predict the prognosis in patients with a pituitary mass. The aim of this study was to evaluate the correlation among 2 diagnostic modalities—MRI and optical coherence tomography (OCT)—and VFDs. Methods: Consecutive patients who showed the presence of a pituitary mass on MRI and in whom ophthalmic examinations were performed were recruited. Height and volume of the mass, sagittal and coronal displacement of optic chiasm, and the direction of mass expansion were measured. Patients were divided into 2 groups according to the presence (VFD group) or absence of VFDs (no VFDs group [NVFD]). The correlation among MRI parameters, OCT parameters, and VFDs were examined, and the diagnostic values of MRI and OCT and the combined value of the 2 modalities were analyzed. Results: Forty-one patients were included. The greatest coefficients of determination were observed between the sagittal displacement and pattern standard deviation (PSD) (R2 = 0.3661, P , 0.001) and between the inferonasal ganglion cell–inner plexiform layer (GCIPL) and PSD (R2 = 0.4079, P , 0.001). The height and the size of the mass in the VFD group were significantly greater as 57% and 148%, respectively, and the VFD group had more severe chiasmal displacement both in the sagittal (165%) and in the coronal (178%) plane (large effect in all). All macular GCIPLs were thinner in the NVFD group (range 9%–26%, large effect), whereas only temporal (25%) and average (11%) values were among peripapillary retinal nerve fiber layers. Conclusions: The highest correlations with the degree of the VFD were seen in the sagittal displacement of optic chiasm and the inferonasal GCIPL, and these parameters were correlated concurrently. Both modalities showed a good diagnostic value for discriminating VFDs. Journal of Neuro-Ophthalmology 2021;41:e541–e547 doi: 10.1097/WNO.0000000000001011 © 2020 by North American Neuro-Ophthalmology Society Department of Radiology (HBS), Pusan National University School of Medicine, Busan, South Korea; Department of Ophthalmology (HC, HJ), Pusan National University Hospital, Busan, South Korea; and Biomedical Research Institute (HC, HJ), Pusan National University Hospital, Busan, South Korea. The authors report no conflicts of interest. Address correspondence to Hyeshin Jeon, MD, Department of Ophthalmology, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan 602-739, Korea; E-mail: [e-mail] Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 V isual field defect (VFD) occurs in 9%–32% of the patients with a pituitary mass. It is considered to be related to compression of the optic nerve due to mass effect (1,2). The optic chiasm is a structure in which the optic nerve fibers partially intersect. An irreversible change can be made in this structure by even small lesions (3). Analysis of VFDs is important in determining the treatment plan and in prediction of the prognosis. Surgery is known to be the first-line treatment of a symptomatic pituitary mass, and the VFD is one of the most important factors in determining the need for surgery. Furthermore, the VFD is the initial and/or the only symptom of the disease in many cases (4). Furthermore, because the severity of visual loss (5), the duration of disease (6), and the presence of optic atrophy (7) are related to visual prognosis, early diagnosis is important to prevent irreversible visual loss. MRI has been used in several studies to measure various parameters of the pituitary mass (1,2,6–8), and these parameters are associated with VFDs. Tumor size is an important factor related to VFDs and postoperative recovery. Suprasellar extension, location, and hormonal activity of the tumors were also correlated with VFDs (1,2,6,8). Although advances in MRI have enabled accurate image acquisition and quantitative analysis, the cost and time required for the analysis is quite high. Chiasmal compression causes change in the appearance of the fundus, which is denoted as band atrophy. This results in changes in the retinal thickness. With advances in optical coherence tomography (OCT), thickness measurement and automatic segmentation of specific layers of retina are possible. Thinning of the retinal nerve fiber layer (RNFL) has been reported in patients with lesions causing chiasmal compression. In recent studies, it has been reported that the ganglion cell– inner plexiform layer (GCIPL) reflects VFDs well (9–11). Furthermore, OCT can detect the correlation between the degree of reduction in the retinal thickness and VFD progression (12). Thus, studying the association among MRI parameters, OCT parameters, and VFDs may be helpful in early diagnosis and determination of the treatment. e541 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution In this study, we investigated the correlation among the morphologic features of tumor measured by MRI, the retinal thickness measured by OCT, and VFDs. We also investigated whether these objective factors can be used to predict the presence of VFDs. METHODS Study Population Given the retrospective nature of this study, the need for obtaining informed consent was waived. This study was approved by the relevant institutional review board. Consecutive patients who showed the presence of a pituitary mass on MRI and in whom ophthalmic examinations were performed from 2015 to 2019 were recruited. Routine ophthalmic examinations in patients with a pituitary mass included best-corrected visual acuity, intraocular pressure, slit-lamp examination, fundus examination, OCT, and visual field test. Only reliable results of a visual field test with false positive errors ,15%, false negative errors ,15%, and fixation loss ,20% were adopted, and 19 patients were excluded. We excluded 3 patients with ophthalmic diseases that could have affected the results of ophthalmic examinations, including retinal disease and glaucoma, and one patient with a history of previous brain surgery. Finally, 41 patients were included in this study. Among them, 29 patients were diagnosed with a pituitary adenoma, and 2 patients were diagnosed with a Rathke cleft cyst on the basis of surgical pathologic examinations. Ten cases were not pathologically confirmed. Analysis of Magnetic Resonance Images All MRI scans were acquired using a 1.5 T Siemens Avanto MRI scanner (Siemens, Erlangen, Germany). Each patient underwent an MRI examination that consisted of T2 (TR 3000 ms, TE 80 ms, FOV 180 mm, slice thickness 2 mm, and 256 · 179 matrix) and T1 sagittal and T1 coronal MRI sequences (TR 350 ms, TE 9.8 ms, FOV 180 mm, slice thickness 2 mm, and 256 · 179 matrix), before and after gadolinium contrast agent administration. The height and size of the mass, the displacement of optic chiasm, and the direction of mass extension were evaluated. The height of the mass was measured using a coronal image and was defined as the length from the lowest part to the top of the mass. We measured 3 maximal diameters (a, b, and c) in 3 orthogonal planes and calculated the mass size using the formula 0.52 (a$b$c) because a pituitary mass is 3-dimensional. Only relevant parameters of the pituitary mass were measured, not including the native pituitary. The method described by Ikeda and Yoshimoto was used in measuring the displacement of optic chiasm (13). A reference line was set between the frontal base and the posterior clinoid process on the sagittal image. On the coronal image, the reference line was set at the upper surface of the bilateral internal e542 carotid artery (ICA). After determining the location of the optic chiasm, the maximum distance between the reference lines and the lower surface of the optic chiasm was measured. The displacement of the optic chiasm is a measure of the superior displacement in the sagittal and coronal planes. The optic chiasm was displaced and thinned by “mass effect,” making it difficult to discern the optic chiasm in 7 patients. In these cases, the maximum distance between the top of the mass and the reference line was measured. The directions of mass expansion were evaluated using the naked eye. We evaluated the mass extension by suprasellar, infrasellar, parasellar, anterior, and posterior (SIPAP) classification (14). There were 5 different juxtasellar directions as follows: superior, inferior, parasellar, anterior, and posterior extensions. The coronal and the sagittal images were evaluated for the classification. The grading system included the following categories: the 5 grades of suprasellar expansion (0 —no bulging, 1—bulging mass without reaching the chiasm, 2—mass reaches the optical chiasm without displacing it, 3—mass displaces and stretches the chiasm, and 4— obstructive hydrocephalus caused by mass extension), the 3 grades of infrasellar extension (0—intact floor of the sella, 1—focal bulging of the mass, and 2—mass penetration beneath the sphenoid sinus), the 5 grades of parasellar extension (0—normal, 1—extends beyond the medial margins but not beyond the intercarotid line of the supracavernous and intracavernous ICA, 2—extends beyond the intercarotid line but not beyond the lateral margins of the supracavernous and intracavernous ICA, 3—extends beyond the lateral margins of the supracavernous and intracavernous ICA, and 4—total encasement of the intracavernous ICA), the 2 grades of anterior extension (0—no extension and 1—grows into the anterior fossa), and the 2 grades of posterior extension (0—no posterior-inferior growth behind the clivus and 1—growth behind and inferior to the dorsum of the sella or the clivus). The representative cases are presented in Figure 1. Ophthalmic Assessment Cirrus HD OCT system (Software V.6.0.2.81; Carl Zeiss Meditec, Dublin, CA) was used. Only the images that exhibited no eye motion were accepted, and the images with signal strength of ,7 were excluded. We measured the peripapillary RNFL thickness and the macular GCIPL thickness. Optic disc cube (200 · 200 A-scans) data were obtained from the data covering an area of 6 · 6 mm2 centered on the optic nerve head, which was determined automatically. The average RNFL thickness and RNFL thickness from the 4 segments (superior, temporal, inferior, and nasal) were obtained. Macular cube (200 · 200 A-scans) data were obtained from the data covering an area of 6 · 6 mm2 centered on the fovea. A layer from the outer boundary of the RNFL to the outer boundary of the inner plexiform layer was determined to be the GCIPL thickness. Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution FIG. 1. Measurements of MRI and optical coherence tomography in the visual field defect (VFD) group and no VFD (NVFD) group. A representative case in the VFD group (A–D). Measurement of pituitary mass height and chiasmal displacement on contrast-enhanced T1 coronal (A) and T1 sagittal (B) images. Normal position of an optic pathway (bar, A and B) and distance from normal position (arrow, A and B) are shown. The coronal (A) image shows 20.04 mm of chiasmal displacement and suprasellar/infrasellar/both parasellar extension of the pituitary mass. The sagittal (B) image shows 7.81 mm of chiasmal displacement. The peripapillary RNFL (C) and the macular GCIPL (D) are shown. E–H. Show a representative case in the NVFD group. Measurement of pituitary mass height on contrast-enhanced T1 coronal (E) and T1 sagittal (F) images. Normal position of an optic pathway (bar, E and F) is shown. The coronal (E) and sagittal (F) images show the presence of a pituitary mass without chiasmal displacement and tumor extension. The peripapillary RNFL (G) and the macular GCIPL (H) are shown. GCIPL, ganglion cell–inner plexiform layer; RNFL, retinal nerve fiber layer. Eight parameters, namely, average, minimum, and 6 sectoral (superotemporal, superior, superonasal, inferonasal, inferior, and inferotemporal) values were obtained. Humphrey field analyzer (Carl Zeiss Meditec, Dublin, CA) was used, and Swedish interactive threshold algorithm (SITA-fast 30-2 program) was adopted. A single neuroophthalmologist evaluate the visual field test result. An abnormal visual field was defined as the presence of at least 2 nonedged points with a probability of ,0.5% and one point with a probability of ,2% with respect to the vertical meridian (14). Only the reliable visual field test results with false positive errors ,15%, false negative errors ,15%, and fixation loss ,20% were adopted. Visual field sensitivity was quantified using the pattern standard deviation (PSD). For analysis of the linear relationship between structure and function (15), the PSD was also converted from dB to 1/Lambert (1/L) units using the formula 1/L 1/4 10 dB/10. parameters, and PSDs. Patients were divided into 2 groups according to the presence or absence of VFDs. Continuous variables were compared between the 2 groups using the Student t test. We also calculated the effect size using Hedge’s g and judged it to be a large effect when the value was .0.8. Differences in the categorical variables were tested by using the x2 test or the Fisher exact test. Analysis of covariance was used to evaluate the effect of variance. The diagnostic abilities of MRI parameters, OCT parameters, and combination of the 2 parameters to predict the VFD were evaluated using receiver operating characteristics (ROC) analysis. Areas under the ROC curves (AUC) were compared. A P value of ,0.05 was considered as a significant result. Statistical Analyses The PSD was significantly correlated with MRI and OCT parameters (Table 1). Among the MRI parameters, we observed the greatest coefficient of determination (R2) between the sagittal displacement of chiasm and PSD (R2 = 0.3661, P , 0.001). The greatest R2 was observed between the inferonasal GCIPL and PSD (R2 = 0.4079, P , 0.001) among the OCT parameters. The correlation Statistical analyses were performed using the SPSS software package (Version 19.0 for Windows; IBM, Armonk, NY) and R software (R Foundation for Statistical Computing, Vienna, Austria). Linear regression analysis was performed to assess the relationship among MRI parameters, OCT Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 RESULTS e543 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 1. The correlations between MRI parameters, OCT parameters, and visual field defect using pattern standard deviation MRI Parameters PSD (1/L) Height Volume Sagittal displacement Coronal displacement OCT Parameters R2 P value GCIPL R2 P value 0.287 0.267 0.366 0.354 ,0.001 0.001 ,0.001 ,0.001 Average Minimum Superotemporal Superior Superonasal Inferotemporal Inferior Inferonasal 0.260 0.408 0.108 0.267 0.382 0.061 0.247 0.450 0.001 ,0.001 0.036 0.001 ,0.001 0.118 0.001 ,0.001 GCIPL, ganglion cell–inner plexiform layer; OCT, optical coherence tomography; PSD, pattern standard deviation. between the sagittal displacement of chiasm and the inferonasal GCIPL is shown in Figure 2. The inferonasal GCIPL showed a significant negative correlation with the sagittal displacement. Patients were divided into 2 groups, comprising of 23 patients with VFDs (VFD group) and 18 patients without VFDs (no VFDs [NVFD] group). The comparison between the 2 groups is shown in Table 2. No statistically significant differences were observed in age, gender, refractive error, and visual acuity between the 2 groups. The VFD group had significantly higher intraocular pressure than the NVFD group (P = 0.038). The height and the size of mass in the VFD group were significantly greater as 57% and 148%, respectively, than in NVFD group (P , 0.05 for both height and volume). The VFD group had more severe chiasmal displacement both in the sagittal (165%) and in the coronal (178%) plane (P , 0.05 for both the views). Large effect size was observed in all parameters. FIG. 2. Scatter plot of the coronal displacement and the inferonasal ganglion cell–inner plexiform layer thickness. GCIPL, ganglion cell–inner plexiform layer. e544 Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 2. Baseline and ocular characteristics of the patients in the 2 groups Age Sex (M:F) IOP Spherical equivalent Visual acuity (log MAR) VFD Group NVFD Group P value 57.6 ± 16.6 11:12 14.1 ± 2.2 21.3 ± 3.2 57.9 ± 14.3 10:08 11.5 ± 3.9 20.7 ± 1.8 0.946 0.860 0.038 0.403 0.5 ± 1.4 0.6 ± 1.6 0.872 IOP, intraocular pressure; NVFD, no visual field defect; VFD, visual field defect. Tumor extension was significantly different between the 2 groups only in the suprasellar direction, with all patients in the VFD group having grade 3 extension (Table 3). All macular GCIPLs were thinner in the NVFD group (range 9%–26%, P , 0.05) and showed large effect size, whereas the peripapillary RNFL differed only in the temporal (25% thinner in the VFD group, P , 0.05) and in the average (11% thinner in the VFD group, P = 0.016) values (Table 4). The ROC curves for MRI parameters and OCT parameters were analyzed to discriminate between the VFD group and the NVFD group. The coronal and the sagittal displacement of chiasm showed the greatest AUC value (0.940) equally among the MRI parameters. Among the OCT parameters, the inferonasal GCIPL showed the greatest AUC value (0.930). The AUC value of the combination of MRI and OCT parameters was elevated to 0.971 (Fig. 3). DISCUSSION MRI is a useful modality in the diagnosis of a pituitary mass. Multiple parameters measured by MRI can provide useful information for predicting VFDs. Several studies have evaluated the relationship between the tumor size and the degree of VFDs, showing that patients with VFDs had larger tumor (7,8,15). Lee et al (1) reported a high correlation between the tumor volume and the severity of VFDs. In agreement with the previous reports, this study found that there was a significant correlation between the tumor height, volume, and VFDs. Vertical growth of tumor can reportedly lead to more severe VFDs, whereas horizontal tumor growth is associated with less visual impairment and increased recurrence rate (16). We found a significant difference in distribution in suprasellar extension according to the presence of VFDs, which was consistent with this finding. The relationship between VFDs and the directions of mass extension was not significant when the tumor extension occurred mainly in the infrasellar, parasellar, anterior, and posterior regions. It is possible to evaluate the positional relationship between the optic nerve and the pituitary mass with high Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 TABLE 3. Intraocular pressure–adjusted means (±standard error) of magnetic resonance image parameters depending on the visual field defect Height Volume Suprasellar 0 1 2 3 Infrasellar 0 1 Parasellar 0 1 2 3 4 Anterior 0 1 Posterior 0 1 Sagittal displacement Coronal displacement VFD Group NVFD Group P value 31.5 ± 1.73 22.4 ± 12.8 20.1 ± 2.0 9.0 ± 3.2 ,0.001 0.005 0.002 0 (0) 0 (0) 0 (0) 23 (100) 2 (11.1) 0 (0) 6 (33.3) 10 (55.6) 20 (87.0) 3 (13.0) 15 (83.3) 3 (16.7) 7 (30.4) 3 (13.0) 9 (39.1) 3 (13.0) 1 (4.3) 4 5 5 2 2 19 (82.6) 4 (17.4) 18 (100) 0 (0) 23 (100) 0 (0) 17.9 ± 1.3 18 (100) 0 (0) 6.8 ± 1.4 ,0.001 18.1 ± 1.3 6.5 ± 1.5 ,0.001 1.000 0.659 (22.2) (27.8) (27.8) (11.1) (11.1) 0.183 1.000 NVFD, no visual field defect; VFD, visual field defect. resolution MRI. Studies have discussed the relationship between chiasmal displacement measured with MRI and VFDs (6,7,13,17). In these studies, visual loss appeared when the optic chiasm was displaced at least 8 mm above the reference line on the sagittal image and at least 12 mm above the reference line on the coronal image. The VFD rarely occurs in patients with less than 3 mm of displacement of the optic nerve from the expected location (18). A significant correlation between chiasmal displacement and VFDs was observed in our study. Furthermore, the coronal and the sagittal displacement of chiasm showed the greatest AUC for discriminating the VFD group from the NVFD group. The highest coefficient of determination was observed in sagittal displacement among MRI parameters and in the inferonasal GCIPL, which were 0.366 and 0.450, respectively. This could be due to the other factors affecting the VFD. It has been reported that patients with pituitary tumors that do not contact the optic nerve also present with VFDs, which could be caused by previous indentation (and subsequent tumor regression), hormonal influences, intratumor hemorrhage, auto-necrosis, or vascular shunting (19). There are recently published studies on the changes of retinal thickness in patients with a pituitary mass (11,12). Also, patients with pituitary tumors even in the absence of chiasmal e545 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 4. Intraocular pressure–adjusted means (±standard error) of optical coherence tomography parameters depending on the visual field defect VFD Group RNFL Average Temporal Superior Nasal Inferior GCIPL Average Minimum Superotemporal Superior Superonasal Inferonasal Inferior Inferotemporal NVFD Group P value 85.1 55.9 109.1 63.6 112.7 ± ± ± ± ± 2.5 3.3 4.1 2.1 4.3 95.7 74.8 120.4 70.4 118.3 ± ± ± ± ± 2.9 3.8 4.7 2.4 4.9 0.013 0.001 0.094 0.051 0.427 71.4 60.2 76.8 70.2 65.5 62.0 69.4 79.1 ± ± ± ± ± ± ± ± 2.3 2.5 1.9 2.1 2.4 2.2 1.8 1.8 86.0 81.4 85.9 86.6 86.9 83.8 81.9 86.9 ± ± ± ± ± ± ± ± 2.7 2.9 2.2 2.4 2.7 2.5 2.1 2.1 ,0.001 ,0.001 0.005 ,0.001 ,0.001 ,0.001 ,0.001 0.011 GCIPL, ganglion cell–inner plexiform layer; NVFD, no visual field defect; VFD, visual field defect; RNFL, retinal nerve fiber layer. compression may present thinning of the ganglion cell complex and the RNFL (10). In addition to chiasmal compression, factors including inflammation of the tumor, growth rate of the tumor, consistency of the tumor, local compromise of blood flow, tumor necrosis, length of the intracranial optic nerve, and the initial spatial relationship between the optic pathway and the pituitary are reportedly related to the displacement of the visual pathway (20). Therefore, a multidisciplinary approach is necessary for timely and accurate diagnosis of VFDs. VFDs in patients with a pituitary tumor occur gradually and are associated with a long period of optic nerve or chiasmal compression (2). Early diagnosis and treatment of the pituitary mass is important for prevention of irreversible visual loss. However, performing a visual field test requires a high concentration and coordination from the patients, which is dependent on the patients’ condition. Conversely, quantitative evaluation of the objective data from the acquired images can alleviate this concern. In this study, image modalities targeting the other 2 anatomical structures (brain and retina) were highly correlated with VFDs. MRI, which can directly understand the anatomical features of the lesion, is time consuming and expensive to apply longitudinally. OCT, on the other hand, enables quantitative evaluation of the retinal layer quickly and easily in cooperative patients. This study has some limitations. The position of the chiasm and laterality in the upward growth of the tumor may be correlated to VFDs. However, in some cases, severe compression occurred because of a large mass and the accurate position and laterality could not be determined. Therefore, we did not include these parameters. Second, not all the patients had a pathologically proven pituitary mass. Hence, differences in the results based on the pathological e546 FIG. 3. The receiver operating characteristic curve for discrimination of the patients with visual field defect from the patients without visual field defect. diagnosis could not be derived. Third, because of the retrospective, cross-sectional nature of this study, we could not determine whether the duration or progression of optic chiasmal compression could affect VFDs. These issues can be addressed in future prospective longitudinal studies. CONCLUSIONS Both MRI and OCT parameters were significantly correlated with the degree of VFDs. Degree of the sagittal chiasmal displacement and the inferonasal GCIPL thickness showed the highest correlation and these 2 parameters were correlated concurrently. These factors were also useful for predicting VFDs and when combined, the predictability was further improved. Appropriate application of image modality is expected to improve the medical decisions regarding diagnosis, treatment, and prediction of prognosis in patients with a pituitary mass. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: H. Jeon, H. Choi, and H. Suh; b. Acquisition of data: H. Jeon and H. Suh; c. Analysis and interpretation of data: H. Jeon, H. Choi, and H. Suh. Category 2: a. Drafting the manuscript: H. Jeon and H. Suh; b. Revising it for intellectual content: H. Jeon, H. Choi, and H. Suh. Category 3: a. Final approval of the completed manuscript: H. Jeon, H. Choi, and H. Suh. REFERENCES 1. Lee JP, Park IW, Chung YS. The volume of tumor mass and visual field defect in patients with pituitary macroadenoma. Korean J Ophthalmol. 2011;25:37–41. Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution 2. Wang H, Sun W, Fu Z, Si Z, Zhu Y, Zhai G, Zhao G, Xu S, Pang Q. The pattern of visual impairment in patients with pituitary adenoma. J Int Med Res. 2008;36:1064–1069. 3. Kane EJ, Ashton DE, Mews PJ, Reid K, Neely A, Lueck CJ. Correlation of MRI findings with patterns of visual field loss in patients with pituitary tumors. J Neuroophthalmol. 2019;39:333–338. 4. Chanson P, Raverot G, Castinetti F, Cortet-Rudelli C, Galland F, Salenave S. Management of clinically non-functioning pituitary adenoma. Ann Endocrinol. 2015;76:239–247. 5. Gnanalingham KK, Bhattacharjee S, Pennington R, Ng J, Mendoza N. The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry. 2005;76:415–419. 6. Gan L, Ma J, Feng F, Wang Y, Cui J, Guo X, Zhang X, You H, Wang Z, Yin Z, Zhong Y, Xing B. The predictive value of suprasellar extension for visual function evaluation in Chinese patients with nonfunctioning pituitary adenoma with optic chiasm compression. World Neurosurg. 2018;116:e960– e967. 7. Monteiro ML, Zambon BK, Cunha LP. Predictive factors for the development of visual loss in patients with pituitary macroadenomas and for visual recovery after optic pathway decompression. Can J Ophthalmol. 2010;45:404–408. 8. Ho RW, Huang HM, Ho JT. The influence of pituitary adenoma size on vision and visual outcomes after trans-sphenoidal adenectomy: a report of 78 cases. J Korean Neurosurg Soc. 2015;57:23–31. 9. Moon CH, Lee SH, Kim BT, Hwang SC, Ohn YH, Park TK. Diagnostic ability of retinal nerve fiber layer thickness measurements and neurologic hemifield test to detect chiasmal compression. Invest Ophthalmol Vis Sci. 2012;53:5410–5415. 10. Cennamo G, Auriemma RS, Cardone D, Grasso LFS, Velotti N, Simeoli C, Di Somma C, Pivonello R, Colao A, de Crecchio G. Evaluation of the retinal nerve fibre layer and ganglion cell Suh et al: J Neuro-Ophthalmol 2021; 41: e541-e547 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. complex thickness in pituitary macroadenomas without optic chiasmal compression. Eye. 2015;29:797–802. Monteiro ML, Costa-Cunha LV, Cunha LP, Malta RF. Correlation between macular and retinal nerve fibre layer Fourier-domain OCT measurements and visual field loss in chiasmal compression. Eye. 2010;24:1382–1390. Yum HR, Park SH, Park HY, Shin SY. Macular ganglion cell analysis determined by Cirrus HD optical coherence tomography for early detecting chiasmal compression. PLoS One. 2016;11:e0153064. Ikeda H, Yoshimoto T. Visual disturbances in patients with pituitary adenoma. Acta Neurol Scand. 1995;92:157–160. Edal AL, Skjodt K, Nepper-Rasmussen HJ. SIPAP-a new MR classification for pituitary adenomas. Suprasellar, infrasellar, parasellar, anterior and posterior. Acta Radiol. 1997;38:30–36. Rivoal O, Brezin AP, Feldman-Billard S, Luton JP. Goldmann perimetry in acromegaly: a survey of 307 cases from 1951 through 1996. Ophthalmology. 2000;107:991–997. Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary. 2012;15:71–83. Schmalisch K, Milian M, Schimitzek T, Lagreze WA, Honegger J. Predictors for visual dysfunction in nonfunctioning pituitary adenomas - implications for neurosurgical management. Clin Endocrinol. 2012;77:728–734. Lee IH, Miller NR, Zan E, Tavares F, Blitz AM, Sung H, Yousem DM, Boland MV. Visual defects in patients with pituitary adenomas: the myth of bitemporal hemianopsia. AJR Am J Roentgenol. 2015;205:W512–W518. Levy A. Pituitary disease: presentation, diagnosis, and management. J Neurol Neurosurg Psychiatry 2004;75(suppl 3):iii47–52. Boland MV, Lee IH, Zan E, Yousem DM, Miller NR. Quantitative analysis of the displacement of the anterior visual pathway by pituitary lesions and the associated visual field loss. Invest Ophthalmol Vis Sci. 2016;57:3576–3580. e547 Copyright © North American Neuro-Ophthalmology Society. 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