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• W2783116658 abstract "Tieger et al (1) reported a series of 23 patients with chiasmal compression evaluated with optical coherence tomography (OCT) and standard automated perimetry (SAP) before and after surgical treatment. Because some of their patients showed complete visual field (VF) recovery despite persistent retinal ganglion cell (RGC) layer thinning on OCT, the authors suggested that RGC loss may precede VF loss, at least when assessed with standard 24-2 or 30-2 threshold strategies. Two invited commentaries pointed out that this is still an unsettled issue regarding compressive disorders of the anterior visual pathway (2,3). I had the opportunity to assess a patient with a pituitary tumor compressing the chiasm, followed for 21 months with OCT, SAP, and manual Goldmann perimetry (GP). My findings strongly support those of Tieger et al. A 56-year-old woman was seen for a follow-up examination because of a nonsecreting pituitary adenoma mildly compressing the optic chiasm. The adenoma was discovered 8 years previously when MRI was obtained for her menstrual irregularities. At that time, the patient had no visual complaints, visual acuity (VA) was 20/20 bilaterally, and the remainder of the ophthalmic examination, including ophthalmoscopy, was normal. SAP (24-2 Swedish Interactive Threshold Algorithm standard test on the automated perimeter) and GP using the I/4e, I/3e, I/2e, and I/1e targets (with kinetic and central static presentations) were also normal. The patient opted for conservative management with visual and neuroimaging re-evaluation every 6 months. Five years later, with the patient still asymptomatic, bilateral VF defects to the I/2e and I/I3 isopters were detected using GP. MRI showed a small hemorrhage within the pituitary tumor, but the patient declined surgery. Six months later, VF improvement was observed, attributed to slight tumor shrinkage found on MRI. She was followed at 6-month intervals, with minimal VF depression (on both perimeters) in the upper temporal quadrant of each eye. Six years after initial evaluation, the patient's acuity remained 20/20 bilaterally, VFs were stable (Fig. 1A), and OCT (3D OCT-2000; Topcon Corp, Tokyo, Japan) in each eye was performed. It showed the peripapillary retinal nerve fiber layer (RNFL) to be within normal limits, but the RGC-inner plexiform layer (IPL) in the macular area displayed few points of significant reduction in each nasal hemiretina (Fig. 1A). The GP showed a few points of missing static presentation to the I/1e target (Fig. 2A). Nine months later, repeat VF examination showed slightly better results on SAP (Fig. 1B), although testing on the GP was unchanged as was the tumor size on MRI. However, OCT revealed a slight reduction of peripapillary RNFL thickness and a larger area of RGC-IPL reduction in each macula (Fig. 1B). One year after that, VA was 20/20 bilaterally, and SAP findings were slightly worse in the right eye and unchanged in the left eye (Fig. 1C). On OCT, there was further thinning of the peripapillary RNFL and of the RGC-IPL in each nasal hemiretina (Fig. 1C). The GP showed slight progression of VF loss, greater in the right eye (Fig. 2B).FIG. 1.: Results of automated visual fields and optical coherence tomography obtained 6 (A), 7 (B), and 8 (C) years after initial neuro-ophthalmic evaluation. OD, right eye; OS, left eye; GCL, ganglion cell layer; MD, mean deviation; RNFL, retinal nerve fiber layer.FIG. 2.: Kinetic (Goldmann) perimetry findings obtained 6 (A) and 8 (B) years after initial neuro-ophthalmic examination. OD, right eye; OS, left eye.To determine RGC-IPL thickness per quadrant (a feature not available on the OCT), raw data were exported to a personal computer and analyzed using Orion OCT image analysis software (Orion; Voxeleron LLC, Pleasanton, CA). These values were calculated in a circular fashion, according to the Early Treatment Diabetic Retinopathy Study, but rotated (45°) to provide quadrantic measurements respecting the vertical and horizontal meridians. After excluding the fovea, values were calculated for the inner and outer segments of each quadrant. A comparison of the first and last OCT measurements showed RGC-IPL reduction in the 4 nasal quadrantic measurements ranging from 11% to 34.5%, right eye, and from 12.2% to 25.3%, left eye. A small percentage thickness reduction was also found in the temporal inner segments bilaterally (Table 1).TABLE 1.: Sequential measurements of RGC-IPL thicknessSeveral studies evaluating patients with VF defects from chiasmal compression have shown that peripapillary RNFL thickness and macular RGC layer thickness are significantly correlated with VF loss on SAP (4–8) and that patients with less structural damage experience greater visual improvement after chiasmal decompression (5–7). In many patients, VF improvement, despite persistent retinal structural damage, may be attributed to restoration of transmission of neuronal impulses in axons that remain viable (2). This had led to the concept that in compressive optic pathway lesions, functional VF loss precedes structural loss, a rationale challenged by the findings of Tieger et al (1). Our patient's preference for conservative management made it possible to compare VF and OCT data prospectively over an almost 2-year (21-month) follow-up period. There was mild deterioration of the VFs over this time period, yet OCT data (especially RGC-IPL thickness) displayed definite worsening in both eyes. Horton (2) suggested that the conventional size III target used in SAP may not be sensitive enough to detect subtle VF loss. The VF results in our patient support this, as the field loss was only well defined using size I (0.25 mm2), I/2e, and I/1e targets on careful GP in the right eye. Also, it is important to notice that even on GP, progressive visual loss was not clearly defined, despite definite reduction of the RGC layer in the left eye. Therefore, it is likely that in chronic compressive lesions, retinal structures are impaired before clinically detectable VF loss. Our findings suggest that structural retinal measurements in addition to VF testing are a useful aid in the diagnosis and follow-up of patients with compressive lesions of the anterior visual pathway." @default.
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• W2783116658 date "2018-03-01" @default.
• W2783116658 modified "2023-09-23" @default.
• W2783116658 title "Macular Ganglion Cell Complex Reduction Preceding Visual Field Loss in a Patient With Chiasmal Compression With a 21-Month Follow-Up" @default.
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• W2783116658 doi "https://doi.org/10.1097/wno.0000000000000625" @default.
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