Preferential Ganglion Cell Loss in the Nasal Hemiretina in Patients With Pituitary Tumor

A 75-year-old woman with new onset headaches and left vision loss, temporal scalp tenderness, and jaw claudication was found to have biopsy-proven giant cell arteritis (GCA). Despite treatment and improvement with prednisone, she later developed left orbital apex syndrome, and an orbital biopsy revealed aspergillosis. After antifungal treatment, extraocular motility improved although vision in the left eye remained no light perception. Clinicians should be aware that fungal orbital apex disease may mimic or complicate steroid-treated GCA.

Original Contribution Preferential Ganglion Cell Loss in the Nasal Hemiretina in Patients With Pituitary Tumor Ah Reum Jeong, MD, Eun-Young Kim, MD, PhD, Na Rae Kim, MD, PhD Background: Analysis of retinal nerve fiber layer thickness and macular ganglion cell layer loss provides a noninvasive method to assess optic chiasmal compression. These techniques may provide valuable data for patient evaluation and management when combined with findings on clinical examination and neuroimaging results. Methods: Data from 20 eyes of 10 patients with pituitary tumor treated at Inha University Hospital from 2011 to 2013 were collected. This included results of ophthalmologic examination, fundus photography, spectral domain optical coherence tomography (SD-OCT), automated visual field testing, and brain magnetic resonance imaging (MRI). Abnormal color patterns on thickness and deviation maps obtained by macular ganglion cell analysis (GCA) were evaluated and compared with visual field defects. Results: Patients with pituitary tumor showed preferential ganglion cell loss in the nasal hemiretina and characteristic vertical midline-respecting perimacular ganglion cell-inner plexiform layer defects, which anatomically matched the visual field defects. Conclusions: Macular GCA using SD-OCT can be used to complement visual field assessment and brain MRI findings during evaluation of patients with pituitary tumor. Journal of Neuro-Ophthalmology 2016;36:152-155 doi: 10.1097/WNO.0000000000000331 © 2015 by North American Neuro-Ophthalmology Society O ptical coherence tomography (OCT) has been shown to detect retinal nerve fiber layer (RNFL) loss in patients with disorders of the visual pathways (1-3). Specifically, compression of the optic chiasm is associated with significantly thinner nasal and temporal RNFL sectors compared with glaucoma, where RNFL loss affects the superior and inferior sectors (4). Previous reports have addressed the importance of adding total macular thickness measurements to the peripapillary RNFL assessment to improve specificity of the findings in patients with chiasmal compression (5,6). One study using spectral domain OCT (SD-OCT) found a stronger correlation between macular inner retinal layer thickness and visual field loss than between total macular thickness and visual field loss in patients with chiasmal compression (7). We report a series of 10 patients with chiasmal compression from pituitary tumor. Their ganglion cellinner plexiform layer (GCIPL) defects were identified using SD-OCT. We correlated the OCT results with the findings obtained on visual field testing, fundus photography, and neuroimaging. METHODS Department of Ophthalmology and Inha Vision Science Laboratory (ARJ, NRK), Inha University School of Medicine, Incheon, Republic of Korea; and Department of Neurosurgery (EYK), Inha University School of Medicine, Incheon, Republic of Korea. Supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (NRF-2013R1A1A1010814) and by INHA UNIVERSITY Research Grant. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the full text and PDF versions of this article on the journal's Web site (www. jneuro-ophthalmology.com). Address correspondence to Na Rae Kim, MD, PhD, Department of Ophthalmology, Inha University Hospital, 7-206, 3-ga, Shinheungdong, Jung-gu, Incheon, Republic of Korea, 400-711; E-mail: nrkim@ inha.ac.kr 152 All patients with peripapillary and macular OCTs performed in a glaucoma clinic at Inha University Hospital between 2011 and 2013 were retrospectively reviewed. Patients with pituitary tumor having GCIPL defect pattern in the nasal hemiretina on ganglion cell analysis maps were selected and their records were examined retrospectively. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Inha University Hospital. Patients underwent brain magnetic resonance imaging (MRI) and ophthalmologic examination, which included a review of their medical history, measurement of visual acuity, slit-lamp examination, applanation tonometry, dilated fundus examination, fundus photography (Canon, Tokyo, Japan), spectral domain optical coherence Jeong et al: J Neuro-Ophthalmol 2016; 36: 152-155 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution tomography (SD-OCT) (Cirrus HD-OCT, Zeiss), and automated perimetry (Carl Zeiss Meditec). RESULTS Twenty eyes of 10 patients were included in this study (see Supplemental Digital Content, Table E1, http://links. lww.com/WNO/A180). Seven patients (Cases 1, 4, 5, 6, 7, 8, and 9) were referred from the neurosurgery service after being diagnosed with pituitary tumor. One patient (Case 2) was found to have a pituitary tumor after visual field testing, whereas 2 patients (Cases 3 and 10) were found to have a pituitary tumor after ophthalmologic examination. Three illustrative cases are presented. Case 1 A 56-year-old man fell, struck his head, and developed a subdural hemorrhage. With neuroimaging, a pituitary adenoma was discovered incidentally (Fig. 1A). Six years later, the patient returned complaining of headache. On ophthalmologic testing, visual acuity was 20/20 in both eyes and visual fields showed an incomplete bitemporal hemianopia (Fig. 1B). The optic discs appeared normal (Fig. 1C). SDOCT showed superior RNFL thinning in the right eye and temporal RNFL thinning in the left eye (Fig. 1D), but these patterns of RNFL loss did not correspond to the visual field results. Binasal GCIPL defects respecting the vertical midline were observed on SD-OCT (Fig. 1E). The patient underwent transsphenoidal surgery for removal of the pituitary tumor. Case 4 A 47-year-old woman with a known pituitary tumor (Fig. 2A) was referred by the neurosurgery department for visual field testing. She was found to have bitemporal field loss, greater in the right eye (Fig. 2B). She underwent transsphenoidal surgery and 4 months later, her visual fields were improved (Fig. 2C). At that time, the optic discs appeared unremarkable (Fig. 2D). SD-OCT demonstrated normal RNFL distribution (Fig. 2E), but GCIPL layer thinning nasally was present in both eyes (Fig. 2F). Case 6 Seven years after surgery for pituitary tumor, a 59-year-old woman was found to have tumor recurrence on MRI (Fig. 3A). On ophthalmologic testing, she had bow-tie optic atrophy in each eye (Fig. 3B) and a complete bitemporal hemianopia (Fig. 3C). SD-OCT revealed temporal and nasal RNFL defects in both eyes (Fig. 3D) and nasal GCIPL defects bilaterally (Fig. 3E). DISCUSSION In our study, we found that perimacular GCIPL measurement by SD-OCT complemented visual field testing in FIG. 1. Case 1. A. Coronal T2 and sagittal T1 magnetic resonance imaging scans show a pituitary tumor. B. Automated perimetry demonstrates an incomplete bitemporal hemianopia. C. The optic discs appear normal. D. On optical coherence tomography, there is retinal nerve fiber layer thinning superiorly in the right eye and temporally in the left eye. E. There is binasal ganglion cell-inner plexiform layer defects on ganglion cell analysis thickness and deviation maps. Jeong et al: J Neuro-Ophthalmol 2016; 36: 152-155 153 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution FIG. 2. Case 4. A. A large pituitary tumor is seen on coronal T2 and sagittal T1 magnetic resonance imaging. Automated visual fields show bitemporal visual field loss (B) with marked improvement 2 months after surgery (C). D. The appearance of the fundi is unremarkable. E. Normal findings on retinal nerve fiber layer thickness and deviation maps. F. Binasal ganglion cell-inner plexiform layer defects are present on ganglion cell analysis thickness and deviation plots 2 months postoperatively. evaluating patients with compression of the optic chiasm. The characteristic nasal GCIPL defects detected in our patients is because crossing nerve fibers originating in the nasal hemiretina are damaged by chiasmal compression, whereas uncrossed fibers originating in the temporal hemiretina are relatively preserved (5). FIG. 3. Case 6. A. Postcontrast coronal T1 and precontrast sagittal T1 magnetic resonance imaging reveals recurrent pituitary tumor. B. Bow-tie optic atrophy is present bilaterally. C. Automated perimetery demonstrates a bitemporal hemianopia. D. On optical coherence tomography, temporal and nasal retinal nerve fiber layer defects are seen bilaterally. E. There are nasal ganglion cell-inner plexiform layer defects on ganglion cell thickness and deviation maps. 154 Jeong et al: J Neuro-Ophthalmol 2016; 36: 152-155 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution Garaway-Heath et al (8) examined the anatomic relationship between regions of the visual field and the optic disc, correlating the course of the RNFL with visual field defects. Axons from nasal and temporal hemiretina generally run parallel and approach the optic disc in sectors, not in a vertical meridian pattern. Thus, scans of the RNFL obtained by OCT are centered on the optic disc. In contrast, GCIPL scans are centered on the macula, as is the visual field. The complementary use of macular OCT and visual field testing aids in selecting patients who require neuroimaging. In addition, combining measurements of RNFL and GCIPL may prove useful in estimating chances for visual recovery after surgical intervention in patients with chiasmal compression. The specific pattern of nasal defects in macular OCT helps to distinguish chiasmal compression from other disorders such as glaucoma. In glaucoma, arcuate scotomas and nasal steps commonly appear as horizontal defects (9). In the early stages of glaucoma, macular GCIPL thinning is predominantly located in the inferotemporal or superotemporal areas around the horizontal raphe (10). This is in contrast to chiasmal disorders where GCIPL defects respect the vertical meridian. In our study, most of the GCIPL patterns showed nasal hemiretinal thinning, but some had concomitant temporal hemiretinal thinning depending on the duration and extent of compression. The finding of temporal hemiretinal thinning has been reported previously in patients with chiasmal compression (6,7). It is assumed that uncrossed temporal nerve fibers at the optic chiasm were damaged before treatment (7). Temporal hemiretinal thinning appears to depend on the extent and duration of chiasmal compression. In addition to a small sample size, there are several limitations to this study. First, in 4 of the 10 patients, RNFL and GCIPL data were only available in the postoperative period, and it is possible that surgery affected these measurements. Second, in most cases, visual field results correlated well with GCIPL defects. In cases with poor-quality OCTs, such as in patients with myopia, visual field findings were superior to GCIPL defect findings. However, OCT findings might be particularly useful in patients with chiasmal lesions who are not capable of Jeong et al: J Neuro-Ophthalmol 2016; 36: 152-155 performing reliable visual fields. Third, GCIPL data may not be useful in cases of severe compressive cases in which the entire GCIPL is diffusely thin ("floor effect"). STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: NR Kim; b. Acquisition of data: AR Jeong, EY Kim; c. Analysis and interpretation of data: NR Kim, AR Jeong. Category 2: a. Drafting the manuscript: NR Kim, AR Jeong; b. Revising it for intellectual content: NR Kim. Category 3: a. Final approval of the completed manuscript: NR Kim. REFERENCES 1. Kanamori A, Nakamura M, Matsui N, Nagia A, Nakanishi Y, Kusuhara S, Yamada Y, Negi A. Optical coherence tomography detects characteristic retinal nerve fiber layer thickness corresponding to band atrophy of the optic discs. Ophthalmology. 2004;111:2278-2283. 2. Monteiro ML, Leal BC, Rosa AA, Bronstein MD. Optical coherence tomography analysis of axonal loss in band atrophy of the optic nerve. Br J Ophthalmol. 2004;88:896-899. 3. Romero R, Guitierrez I, Wang E, Reder ET, Bhatti MT, Bernard JT, Javed A. 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