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Clinical Characteristics and Ophthalmologic Findings of Pituitary

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Clinical Characteristics and Ophthalmologic Findings of Pituitary Int Ophthalmol (2019) 39:21–31 https://doi.org/10.1007/s10792-017-0778-x (0123456789().,-volV)(0123456789().,-volV) ORIGINAL PAPER Clinical characteristics and ophthalmologic findings of pituitary adenoma in Korean patients Tae Gi Kim . Kyung Hyun Jin . Jaheon Kang Received: 11 June 2017 / Accepted: 24 November 2017 / Published online: 22 December 2017 Ó Springer Science+Business Media B.V., part of Springer Nature 2017 Abstract visual field defects was found in 36.1% of patients. Purpose To investigate the clinical characteristics of Tumor volume was positively correlated with visual and ophthalmic findings in Korean patients diagnosed field pattern standard deviation (PSD, p = 0.020) and with a pituitary adenoma. best-corrected logMAR visual acuity (p = 0.000) and Methods The medical records of 534 patients diag- negatively associated with tumor volume and visual nosed with a pituitary adenoma at Kyung Hee field mean deviation (MD, p = 0.000). Best-corrected University Hospital between January 2007 and visual acuity (p = 0.000), MD (p = 0.001), and PSD December 2016 were retrospectively reviewed. (p = 0.028) significantly improved after surgery. Results Mean patient age was 47.9 ± 16.2 years. Conclusions Pituitary adenoma patients do not The most common symptoms at the time of presen- always have ocular symptoms at their first presenta- tation were headache (26.2%) and visual disturbance tion, even when optic chiasm compression and visual (12.4%). The referral rate to the ophthalmology field deficits are present. Therefore, collaboration with department was 18.44% and patients most often an ophthalmologist is important when evaluating presented to the neurosurgery department. Optic pituitary adenoma patients. chiasm compression was identified in 23.4% of patients (54.4% of patients referred to ophthalmology, Keywords Pituitary adenoma Á Visual field Á 15.0% of patients not referred to ophthalmology). Epidemiology Normal visual field (57%) was the most common visual field feature followed by bitemporal hemianop- sia (17.8%). Optic chiasmal compression without Introduction T. G. Kim Á J. Kang (&) The optic chiasm is the point at which optic nerves Department of Ophthalmology, Kyung Hee University partially cross after passing through the optic foramen. Hospital at Gangdong, Kyung Hee University, # 892, Pressure on the optic chiasm by a pituitary tumor can Dongnam-ro, Gangdong-gu, Seoul 05278, Republic of Korea cause bilateral visual disturbances, visual field defi- e-mail: [email protected] cits, and color vision disorders [1, 2]. Pituitary adenoma is the most common benign tumor of the K. H. Jin central nervous system, accounting for 10–15% of all Department of Ophthalmology, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Republic brain tumors, and is estimated (via autopsy) to occur in of Korea 20–25% of the general population [3, 4]. When a 123 22 Int Ophthalmol (2019) 39:21–31 growing tumor presses on the optic chiasm, decreased optical coherence tomography (OCT) to confirm the visual function can result. However, collaboration absence of disc abnormalities and exclude the possi- with multiple departments, including neurosurgery, bility that visual field changes were caused by neurology, ophthalmology, endocrinology, and inter- glaucoma. We also used these images to evaluate nal medicine, is necessary when evaluating pituitary nasal and temporal optic disc atrophy and papilledema adenoma patients because symptoms are not limited to caused by optic chiasm compression associated with ocular problems. In 1978, Klaubet et al. [5] reported the pituitary adenoma. The chief complaint at presen- that the chief complaint in patients with pituitary tation was based solely on patient-reported symptoms adenoma is decreased visual function. However, with and did not consider ophthalmic testing results or neuroimaging advances in the 1980s (e.g., brain systemic examination findings. magnetic resonance imaging [MRI] and computed Tumor location was categorized as intrasellar or tomography [CT]) and more accurate hormone detec- suprasellar extension, and tumor-associated optic tion tests, hormone-associated systemic symptoms chiasm compression was categorized as present or have become the most common onset manifestations absent based on brain MRI findings. Brain MRI was [6, 7]. also used to determine whether chiasm compression Visual field defects and decreased vision occur in included optic chiasm contact with or abutment to the 9–32% and 4–16% of pituitary adenoma patients, tumor. Tumor horizontal and vertical dimensions were respectively [8–10]. However, the actual incidence of measured in the axial plane and tumor height was these symptoms is likely higher because subtle measured in the coronal plane. Tumor volume was changes in the visual field and vision are often difficult calculated as the product of the height, horizontal to identify subjectively. Klauber et al. [5] showed that length, and vertical length. The department of the first 37% of patients with pituitary adenomas did not visit was defined as the department in which the complain of visual field problems, but had defects patient first presented for symptoms associated with identified by visual field testing. Given that quality of pituitary adenoma. The presence and type of surgical life decreases with disease progression, collaboration treatment was determined by examining the medical with ophthalmologists is important when evaluating records in each patient. Pituitary adenoma function pituitary adenoma patients. Unfortunately, few studies was characterized as functional or non-functional have examined ophthalmologic examinations and based on the combined pituitary stimulation test ophthalmology referral rates in pituitary adenoma results. patients diagnosed in other departments [11–13]. Ophthalmic examination included measurement of Therefore, the purpose of this study was to evaluate best corrected visual acuity (BCVA) and intraocular the clinical features of and ophthalmic findings in pressure. Patients with a prior history of intraocular patients diagnosed with pituitary adenomas. These surgery or ocular disease known to affect visual field findings from various points of views are discussed. testing were excluded. The BCVA was measured in both eyes using a logarithm of the minimum angle of resolution (logMAR) chart. The mean value of both Methods eyes was used in analyses. The visual field test was performed using the automated HumphreyÒ Visual The medical records of 534 consecutive patients Field Analyzer II (Carl Zeiss Meditec, Inc., Dublin, diagnosed with pituitary adenomas between January CA, USA) using the Central 24-2 Swedish interactive 1, 2007 and December 31, 2016 at Kyung Hee threshold algorithm (SITA). The visual field test was University Hospital were retrospectively reviewed. conducted on the right eye first, followed by the left, For each patient, sex, age at diagnosis, chief complaint after refractive error correction. Patients who had at presentation, features of brain MRI, and the more than 20% fixation losses or more than 33% false department first visited were investigated. If oph- positive or false negative responses were excluded thalmic examination was performed, visual acuity, from analyses. intraocular pressure, and visual field findings (auto- Visual field defects were classified using the Grey mated visual field test) were also included in analyses. scale for visual field tests. Mean values between the All patients had undergone fundus photography and right and left eyes were calculated and used in analyses 123 Int Ophthalmol (2019) 39:21–31 23 for mean deviation (MD) and pattern standard devi- Table 1 Distribution of age and sex in patients with pituitary ation (PSD). Visual field defects were classified into adenoma ten types, with other types classified as ‘‘atypical’’ Age (years) No. of patients (%) (Fig. 1). Male Female Total All statistical analyses were performed using SPSS statistical software (version 18.0, SPSS, Inc., Chicago, \ 10 0 0 0 (0.0) IL, USA). Pituitary adenoma patients were divided 11–20 10 17 27 (5.1) into two groups according to the presence or absence 21–30 21 44 65 (12.2) of optic chiasm compression, as identified by brain 31–40 29 57 86 (16.1) MRI imaging. Differences between groups in MD, 41–50 37 91 128 (24.0) PSD, and BCVA were compared using independent 51–60 38 57 95 (17.8) sample t-tests. Correlations between visual acuity and 61–70 38 47 85 (15.9) tumor volume, MD, and PSD were analyzed using 71–80 17 25 42 (4.9) Pearson’s correlation tests. Pre- and post-operative [ 80 5 1 6 (1.1) values of MD, PSD, and BCVA were compared using Total 195 (36.5) 339 (63.5) 534 (100) paired sample t-tests. Statistical significance was Mean age 49.9 46.6 47.9 defined as p \ 0.05. Results Patients who did not visit the ophthalmology depart- ment had a mean age of 47.4 ± 16 years at the first This study included 534 patients (195 male, 399 visit. Patients who did visit the ophthalmology female) with a mean age of 47.9 ± 16.2 years (range department had a mean age of 49.5 ± 17 years at 10–86 years) at the time of diagnosis. The relative the first visit. Examination of age distribution revealed proportion of females was highest for patients that patients over 50 years of age had a higher 50–59 years old (male:female = 37:91), with the frequency of visiting the ophthalmology department proportion of males gradually increasing after the (Fig. 2). Mean tumor volume was 8.4 ± 10.9 cm3. age of 60 (Table 1). In total, 114 of 534 patients (21.3%) visited the ophthalmology department. Symptoms at presentation The most common symptoms at presentation were headache (26.2%), galactorrhea and amenorrhea (17.0%), acromegaly (13.7%), and decreased vision (12.4%). In patients who visited the ophthalmology Fig. 2 Age at diagnosis in patients who were referred to the ophthalmology department (filled square, n = 114) and who Fig. 1 Types of visual field defects according to visual field were not referred to the ophthalmology department (filled circle, patterns n = 420) 123 24 Int Ophthalmol (2019) 39:21–31 department, the most common initial presenting group that visited the ophthalmology department had symptoms were headache (30.7%), decreased vision suprasellar extension.
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