Bitemporal Hemianopia Caused by an Intracranial Vascular Loop

ser photocoagulation to the tumor excision and has been shown to in- cluding tumors and carotid artery surface and surrounding retina was crease patient survival.5 aneurysms1; however, reports of bi- provided. Visual acuity continued to temporal field loss from compres- decrease to 20/70 OD at 17 months, Carol L. Shields, MD sion by an abnormal vessel are rare.2 so PDT was performed (Figure). Miguel A. Materin, MD We describe a patient with a non- The entire astrocytoma was treated Brian P. Marr, MD progressive bitemporal hemiano- with a single 83-second laser spot at Jaime Krepostman, MD pia in whom there appeared to be 689 nm (50 J/cm2) following intra- Jerry A. Shields, MD compression of the optic chiasm by 2 venous verteporfin (6 mg/m ). Af- Correspondence: Dr C. L. Shields, an elongated right anterior cerebral ter treatment, resolution of macu- Ocular Oncology Service, Wills Eye artery (ACA). lar exudation, edema, and subretinal Institute, Ste 1440, 840 Walnut St, fluid led to improved vision of 20/50 Philadelphia, PA 19107 (carol Report of a Case. A bitemporal OD (at 1 month) and 20/30 OD (at [email protected]). hemianopia was found in a 65-year- 4, 8, and 12 months). The tumor Author Contributions: Dr C. L. old woman with no vascular risk fac- showed minimal involution with de- Shields had full access to all the data tors during a routine eye examina- creased intrinsic vascularity. in the study and takes responsibil- tion in 2003. Magnetic resonance ity for the integrity of the data and imaging (MRI) results were nor- Comment. Benign retinal astro- the accuracy of the data analysis. mal. One year later, the bitemporal cytic tumors include astrocytic ham- Financial Disclosure: None re- field defect was still present and a artoma, acquired astrocytoma, and ported. second MRI again showed no evi- 1 Astrocytic reactive retinal gliosis. Funding/Support: This study was dence of a compressive or infiltra- hamartoma is typically stable, rec- supported by the Retina Research tive process. ognized in early childhood, and of- Foundation of the Retina Society, The patient was subsequently re- ten found in patients with tuberous Cape Town, South Africa (Dr C. L. ferred to us for an assessment. On sclerosis complex or neurofibroma- Shields), the Paul Kayser Interna- examination, her visual acuity was tosis.1,3 Acquired astrocytoma is a tional Award of Merit in Retina Re- 20/20 OU with normal color vision sporadic tumor with progressive search, Houston, Texas (Dr J. A. and pupillary responses. The fundi growth, retinal detachment, and Shields), Michael, Bruce, and Ellen appeared normal with no evidence poor visual acuity and requires Ratner, New York, New York (Drs of tilted optic discs or retinoschi- enucleation.1,2 This tumor is typi- C. L. Shields and J. A. Shields), the sis. A bitemporal hemianopic sco- cally found in young or middle- Mellon Charitable Giving from the toma was detected by kinetic perim- aged adults and is not associated Figure 1A), and static Martha W. Rogers Charitable Trust, etry ( with tuberous sclerosis complex. perimetry revealed a bitemporal Philadelphia, Pennsylvania (C. L. Retinal gliosis generally occurs fol- hemianopic defect, denser inferi- Shields), the LuEsther Mertz Retina lowing trauma, inflammation, or orly than superiorly, with a pattern Research Foundation, New York (C. infection. and severity unchanged from the ex- L. Shields), and the Eye Tumor Re- Acquired retinal astrocytoma amination performed 20 months ear- search Foundation, Philadelphia shows poor response to laser pho- lier (Figure 1B). Multifocal electro- (Drs C. L. Shields and J. A. Shields). tocoagulation and radiotherapy. retinography results were normal, Mennel and associates4 described a 1. Shields JA, Shields CL. Glial tumors of the retina but visual evoked potentials showed similar case in which an astrocy- and optic disc. In: Shields JA, Shields CL, eds. a mild bilateral delayed response. It Atlas of Intraocular Tumors. Philadelphia, PA: Lip- toma produced a visual acuity of 20/ pincott Williams & Wilkins; 1999:269-286. was noted that the 2 previous MRIs 200 OD from serous retinal detach- 2. Shields CL, Shields JA, Eagle RC Jr, Cangemi F. had been performed without mag- Progressive enlargement of acquired retinal as- ment, exudation, and edema. After trocytoma in two cases. Ophthalmology. 2004; nification and did not consist of thin 166 seconds of PDT, the retinal find- 111(2):363-368. sections. ings gradually cleared during 1 year, 3. Zimmer-Galler IE, Robertson DM. Long-term ob- A repeat MRI with thin-slice servation of retinal lesions in tuberous sclerosis. with a final visual acuity of 20/30 Am J Ophthalmol. 1995;119(3):318-324. and magnified views of the optic OD. Surprisingly, the tumor nearly 4. Mennel S, Hausmann N, Meyer CH, Peter S. chiasm was obtained and showed completely disappeared. In our case, Photodynamic therapy for exudative hamar- a vessel indenting the optic chiasm toma in tuberous sclerosis. Arch Ophthalmol. the retinal findings and visual acu- 2006;124(4):597-599. superiorly (Figure 2A). A com- ity cleared, but the tumor showed 5. Eljamel MS. New light on the brain: the role of puted tomographic angiogram photosensitizing agents and laser light in the trace reduction in size at 8 months management of invasive intracranial tumors. confirmed an elongated right ACA following PDT. Technol Cancer Res Treat. 2003;2(4):303-309. that dipped inferiorly, compressing In other fields of oncology, the the superior aspect of the optic photodynamic technique is impor- chiasm before looping anteriorly tant in the detection and treatment (Figure 2B). The ACA loop was of tumors, particularly brain tu- Bitemporal Hemianopia thought to be the cause of the mors, such as malignant gliomas, Caused by an Intracranial patient’s bitemporal hemianopia. metastatic tumors, and meningio- Vascular Loop We decided against neurosurgical mas. Photodynamic therapy pro- intervention but recommended vides targeted destruction of remain- Optic chiasmal syndrome can be that the patient be evaluated at ing tumor cells following surgical caused by a variety of lesions, in- regular intervals.

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150 30 150 30

165 15 165 15

180 0 180 0

195 345 195 345

210 330 210 330

225 315 225 315

240255 270 285 300 240255 270 285 300

MD – 9.09 dB, P < .5 MD – 10.41 dB, P < .5 PSD 11.24 dB, P < .5 PSD 12.35 dB, P < .5

Figure 1. A, Kinetic perimetry showing a bitemporal hemianopic scotoma. B, Static perimetry with Swedish interactive threshold algorithm fast 24-2 strategy showing a bitemporal hemianopia that is denser inferiorly than superiorly. MD indicates mean deviation; PSD, pattern standard deviation.

S A B

Figure 2. A, T2-weighted coronal magnetic resonance imaging showing impingement and downward displacement of the optic chiasm (asterisk) by a vessel (arrow). B, Reconstructed coronal computed tomographic angiography shows an elongated right anterior cerebral artery that curves downward, forming a loop (arrow) that corresponds to the point of contact with the optic chiasm. The opposite anterior cerebral artery has a normal structure.

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Comment. Vascular compression Our case highlights the impor- gression, it is probably best to fol- of the optic chiasm causing a tance of not only obtaining appro- low up in patients with this rare bitemporal field defect is most priate neuroimaging studies but also condition. often due to an aneurysm of the specifying the region of interest. The ACA, internal carotid artery, or presence of a bitemporal hemiano- Celia S. Chen, MBBS, MPH anterior communicating artery.1 pia in the absence of optic nerve or Phillipe Gailloud, MD Rare cases of dolichoectatic and retinal pathology suggested a pro- Neil R. Miller, MD atherosclerotic ACAs that cause cess involving the optic chiasm. By Correspondence: Dr Miller, Wilmer bitemporal hemianopia have been obtaining thin-sectioned, magni- Eye Institute, Johns Hopkins Hos- reported, but direct chiasmal fied views of this region, we were pital, Maumenee 127, 600 N Wolfe impingement has not been able to identify an anomalous loop St, Baltimore, MD 21287 (nrmiller described. The field defect in such of the right ACA, which appeared to @jhmi.edu). cases is thought to result from be compressing and causing down- Financial Disclosure: None re- traction on small perforating ves- ward displacement of the chiasm, ported. sels causing a chiasmal infarction.2 presumably causing the bitemporal In addition, although Bergaust3 defect. A computerized tomo- reported a patient with a bitempo- graphic angiogram further clarified 1. Bakker SL, Hasan D, Bijvoet HW. Compression ral hemianopia that was thought the process. of the visual pathway by anterior cerebral ar- to be caused by compression of Although surgery can be per- tery aneurysm. Acta Neurol Scand. 1999;99(3): 4 204-207. the inferior aspect of the optic chi- formed in this setting, surgical ma- 2. Hilton GF, Hoyt WF. An arteriosclerotic chias- asm by an anomalous internal nipulation may disrupt the small mal syndrome. JAMA. 1966;196(11):1018-1020. 3. Bergaust B. Unusual course of internal carotid carotid artery, we are unaware of perforating vessels supplying the op- artery accompanied by bitemporal hemianopia. any cases of presumed vascular tic chiasm and result in worsening Acta Ophthalmol (Copenh). 1963;41:270-274. compression of the chiasm with of a preexisting visual field defect or 4. Post KD, Gittinger JW, Stein BM. Visual im- provement after surgical manipulation of doli- production of a bitemporal field even complete blindness. Thus, un- choectatic anterior cerebral artery. Surg Neurol. defect by a vascular loop. less there is clear evidence of pro- 1981;15(4):321-324.

Ophthalmological Ephemera

n 1795, Dr Isaac Thompson concocted an eye water of zinc sulfate, saffron, camphor, and rose water. It was sold as late I as 1939. This is 1 of a series of 32 medical trade cards advertising the product from 1875 through 1895.

Courtesy of: Daniel M. Albert, MD, MS.

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