Chapters Transcript The Road Less Travelled: Transorbital Neurosurgical Approaches Speaker: Lilly H. Wagner, MD This is August 18th rounds. I'm going to present on transorbital neurosurgical approaches, both the surgical concept of it, indications, and then a few clinical cases that we have done here at Mayo. Learning objectives for this lecture are to identify the different approaches that we have to the skull base, recognize indication for transorbital surgery, and compare the risks and benefits of these different approaches. The question that uh you'll all be able to answer after this lecture is, what is the primary anatomic location that is targeted by transorbital neurosurgery? Is it the pituitary gland, the lateral anterior skull base, the brain stem, or the frontal lobe? Few basics here back to neuroanatomy. The skull base is the bottom part of the bony skull. Can I get another half. No, no, um, Caroline, maybe we can mute our non-presenting participants if you're able to do that as organizer. Um, And both the bones and the brain that is resting on those bones. And you can see here on the intracranial view of the bones that the sphenoid bone is sitting in the front there of the skull base, and of course, we know the sphenoid bone is very central to the uh orbit as well, being um the home to the optic canal, the superiorbital fissure, and the orbital apex, and that's really the key element that we travel through in transorbital neurosurgery. This concept of accessing the brain through the skull base is not new. We, um, uh, all know Harvey Cushing, a very famous neurosurgeon who pioneered actually transnasal approaches to the pituitary already in the early 1900s. However, at that time, due to lack of endoscopic equipment, the visualization and Ability to obtain hemostasis were very poor, and this was considered unsafe and abandoned for classic open transcranial approaches. But then with endoscopic equipment and excellent visualization becoming available, endonasal approaches became established and really the mainstay for pituitary surgery, for example, in the 1990s. We can see here that um traveling through the nose gives us access to a pretty narrow area in the center of the skull base, as you can imagine with that trajectory shown in this Mayo illustration. And if we wanna go more lateral, we have to either choose one of these many craniotomy approaches that are outlined here, or we can use a transorbital approach that gives us access to the lateral part of the middle cranial fossa here, or Um, even more medially if we combine it with an endonasal approach. The key element here is the internal carotid artery that crosses between these two approaches that we can't pass with our surgical instruments. There are many transorbital corridors. You can see that surgeons have used all four walls of the orbit to reach different structures. We can reach the sinuses, we can reach the anterior cranial fossa through the orbital roof, but those places really can be reached easier, more effectively through other approaches in general, with normal anatomy. So, really, what our practice and most Transorbital surgery is focused on is this lateral orbital wall approach, and you can see here lined out is TF is the temporal fossa, and then the middle cranial fossa that we reach through the posterior part of the greater wing of the sphenoid. And then here on the intracranial view, you see corresponding in yellow, the area that we can reach when we go through the greater wing of the sphenoid in the orbit, this lateral skull base here in the middle cranial fossa. The concept of transorbital neurosurgery was more broadly introduced in 2010. Um, Chris Mose, a neurosurgeon at the University of Washington in Seattle, was the first one who pioneered this concept, and his pilot study included 16 patients with 20 tones procedure for a long list of indications. He had patients who had Um, traumatic fractures of the skull base, who had a CSF leak after prior surgery, patients who required optic nerve compression or had tumors of the skull base. So, already in this initial paper, there were many different indications, and they found that overall, this was a very safe procedure with few complications, and they were effectively able to treat all of those different problems. Some of the advantages and disadvantages, speaking very broadly, are that this is a minimally invasive technique. So of course, patients always like having a smaller incision. All our comprehensive colleagues and re segment colleagues go through this with cataract surgeries. Incisions get smaller and smaller, and that's what patients want, and that's what we often find more safe in terms of infection risk and healing. We have a very small external incision compared to a craniotomy approach. There is decreased brain retraction, because you can imagine traveling through the orbit gets us right into that lateral skull base, where traveling through the brain, there is a lot of brain in the way before you get actually to the skull base that has to be retracted for many hours. We, um, don't have a lot of systematic data on it, but certainly anecdotally, and from some, uh, some preliminary findings and literature, these patients are shorter in the hospital for a shorter time and on the OR table for a shorter time. And if there's tumors that are both in the skull base and orbit, we have direct access to orbital tumor components, which for us as orbital surgeons, we're much more comfortable approaching it this way than when we work with our neurosurgery colleagues through a craniotomy and have to approach the orbit that way, which is very unfamiliar for us. For the neurosurgeons, of course, they have the opposite challenge here. For them, this is a very different perspective with different landmarks. They have to work through a long and narrow corridor. You see on the bottom here how this looks when we extend the eyelid crease incision and remove bone. You're looking at the front of the temporal lobe in this bottom picture. So they have to work through this corridor, and that's the only exposure they have of the brain, which can be expanded with endoscopic instruments. And the angle of their instruments themselves, of their surgical instruments is limited, of course, by the globe and the bony orbit. Um, so we have to think about that ahead of time, what angle we need to maneuver. The main indications in our practice are lateral anterior skull base lesions and lesions of the orbital apex that we can't reach with a simple orbittotomy. And then in the literature, it's also well established that this is an um an option for reaching the lateral cavernous sinus, which is very challenging to reach through craniotomy. We haven't personally done it in our practice, but are certainly planning to incorporate this. Both traveling along the inside of the orbital wall or the outside of the orbital wall are options and um are used for slightly, reaching slightly different locations. We do, uh, find it essential that an orbital surgeon is part of this. As you all know, there are many critical soft tissue structures in the orbit that we have to work around. I don't know if any of you saw this in the, um, uh, popular, uh, press, but there was a report about a, um, anterior cervical spine tumor being removed through a transorbital approach. Uh, going, they went through the orbital floor and maxillary sinus, and um this was done in Maryland, and they, um, as far as I understand from reading through the background, did not have an orbital surgeon on the team, and there was a very lively discussion in ophthalmology and surgeons groups about this, and obviously we do not want non-orbital surgeons to just dig around in the orbit because it's more than just a A corridor. They called it the third nostril in their article, which, you know, was, was funny, but also um a little bit scary. So, of course, we have to be mindful of all these structures, we have to protect them. There can be injury from um thermal forces like an endoscope, there can be injury from mechanical forces like a cautery or drill, and it's very dangerous to travel through the lateral orbital wall near the orbital apex without being Very familiar with these structures and how to protect them. We generally stay subperiosteal if we want to get to the skull base to keep the fat out of the way and protect everything that's contained in the periorbita. But of course, if we have a lesion in the orbital apex or arising from the optic nerve, we have to open the intramuscular septum to reach that lesion. Here you can see one more time how closely related the orbit really is to the cavernous sinus. Um, we know this from, from clinical pictures, of course, where cavernous sinus pathology presents with eye problems, but also anatomically and surgically. On the left side, you see the superior orbital fissure opened up with the nerves crossing through, and then here the uh trigeminal ganglion and the carotid that are uh in contained in the cavernous sinus. And then on the right side here, you see marked out the superiorbital fissure, that uh if we travel just lateral to it, which is what we do during our lateral um orbital approach to the skull base, we end up just right next to the cavernous sinus. There are some larger case series now that give us good data on on safety. This group did a meta-analysis that was published this year, where they specifically looked at outcomes of sphenoorbital meningioma resection, which is one of the most common indications for Uh, transorbital neurosurgery, they included a total of 9 studies with 216 patients. They found a good rate of subtotal or total resection rates of 86%, which is comparable to open transcranial approaches. They had a relatively low rate of complications, which is considered acceptable, um, because it's comparable again to open transcranial approaches, 10% of visual deficit, 8% diplopia. And overall, their conclusion was that this is an effective technique with low complication rates. Considering this rising popularity, we also included this into our practice here at Mayo, and I'm gonna present 3 cases that we treated with our colleagues from neurosurgery. The first case was a 60-year-old woman. She had uh frequent seizures for 5 years, occurring um 1 to 3 times a month. She was unable to get this controlled with medical treatment and was referred to neurosurgery for consideration of treatment of the encephalocele that was thought to be causing the seizures. We were consulted for consideration of a trans-orbital approach. Here you see imaging. This is a little bit um unusual view for us. It's an oblique view that shows the temporal lobe, and you can see here on the left side more than the right, there's the uh temporal lobe hernia. And one more time here on the um axial CT scan, you can see how we're gonna approach this. There is the area that we want to get to, and we can travel along the lateral orbital wall. And in this case, we decided to do an extra-orbital approach, uh, taking off a bone window at the rim, and then, um, entering the middle cranial fossa this way. We did surgery as planned. The encephalocele was resected through Licre's incision. Patient could be discharged home on post-op day one. She is, uh, seeing me here 3 days after surgery, was recovering well, no pain, no vision problems, no double vision. And, um, on the bottom, you can see again, here the lesion, and then here after resection of that incarcerated brain tissue. And now 3 months out, she's doing well and is seizure-free. The next case is a 55-year-old male who had a recurrent left sphenoid meningioma after prior surgery done elsewhere 5 years ago. Um, unfortunately, he was at the same time diagnosed with colon cancer here at Mayo and was awaiting treatment for that. And considering this added comorbidity and the prior craniotomy, uh, we decided that it would be safest to do a transorbital resection of this lesion. Here, you see his prior craniotomy scar. And on the CT you can see the mesh, and you can imagine that reopening a wound and a cranioplasty like this carries a high risk of healing problems and other complications. It's not easy to close that a second time. Again, there's the lesion, and here's our planned approach. And we did surgery as planned. He did very well. He was discharged on post-op day 2, which is um really would be unheard of after a redo craniotomy. Um, I saw him 2 weeks after surgery. He was doing well. No pain, no double vision, normal eye exam, and minimally visible scar. Again, he is the legion, and that was our approach. The last case is a 55-year-old female who has a history of an adenocarcinoma of a salivary gland that was originally resected back in 2015. She had a neck metastasis just a few months later that was treated with neck dissection. Um, all this was done at an outside institution. She was then found on surveillance imaging to have a mass, uh, located in her sphenoid bone. Um, that was along the lateral orbital wall here and extending into the middle cranial fossa. She was told that she would need a craniotomy for biopsy, and she came to us for a second opinion. Here's the lesion, and you can see the bony disruption here on the CT scan. So we did this case together with neurosurgery. We offered her a transorbital resection through upper lip crease incision, which she wanted to proceed with. I uh took out this bone window and then I resected the anterior part of the greater wing of the sphenoid and the anterior part of the tumor until it got to the intracranial component. My neurosurgery colleague then resected the posterior part. Fortunately, the dura was intact. Frozen sections revealed that this was metastatic adenocarcinoma, but because, because we had good exposure, and as far as we knew, this was a solitary metastasis, we did decide to resect the entire lesion if we can. She was then treated with adjuvant proton beam and chemotherapy. Here she is on post-op day one with expected swelling and bruising, but she was doing well with pain controlled with oral medication, could be discharged home. No vision problems, no double vision. Six months later, after completing radiation, she saw me. She had a little bit of ptosis, but also had a lot of dry eye. So I treated her conservatively and saw her back after a year. And here she is, still with a little bit of ptosis. Her dry symptoms are better. She really doesn't like the ptosis, so I did offer her surgery. You can see here the slight asymmetry in her MRD1. And we just did an external evator advancement, and she was very happy with her results, and she's now 3 years out from surgery, doing well, no signs of recurrence. Here's our multiple choice question again. What is the primary anatomic location targeted by transorbital neurosurgery? Is it the pituitary gland, lateral anterior skull base, brain stem, or frontal lobe, and of course, you all know now, it's the lateral anterior skull base. I'm very grateful for the excellent collaboration that we have here at Mayo with our colleagues from rhinology and neurosurgery. This allows us to be one of the few centers in the country that offers these approaches. It's a growing practice. Patients learn about this and want this, and it is really safer in some instances, as, for example, for patients who would otherwise need a repeat craniotomy. And I hope we um can continue to grow this. So send any patients our way that you think would be a candidate, and I'm happy to take any questions or pass it on to Doctor Coors. Hey, Lily. Yeah, Greg Riebenttrag here. Um, great presentation. Thank you so much. Can you explain to our colleagues a little bit about the logistics of how this is pulled together? Because I think from, you know, an ophthalmologist's standpoint, it might be difficult to understand how much actual coordination it takes to make a case like this work. Yeah. Yeah. So, you know, these are not our typical combined cases where um colleagues from ENT may ask us to pop into the room for 30 minutes and place a gold weight. Um, this definitely puts a significant strain on our time and resources, and I think that's one of the reasons why there's not a lot of centers that offer it, because there are definitely barriers to, um, doing these combined cases. When we do a trans-orbital approach, we really are the, um, 50% co-surgeon, and we are scrubbed in at least 50% of the time, and these are usually 7 or 8-hour cases because we do the entire exposure. We often assist with visualization while the neurosurgeon is working, and then we do closure. So, these could be 8-hour cases for us and require us to be in a non-ophthalmology room for the entire day. So, we're very fortunate here that we have support from our leadership to do these cases and to be actually Um, off the floor as far as ophthalmology is concerned for the whole day, but that's what's required. And we, um, are very thankful that we have this opportunity here, but certainly, it's an expansion from our combined surgical practice that's very, um, time-consuming and definitely requires a deliberate approach and being aware of what it takes and, um, making arrangements accordingly. Great. So if there's no other questions, then I'm gonna let Doctor Cos take over. Yes, thank you. Great presentation. I am going to share my screen here quick. Let's get started. So, I'm Jackie Kors and I'm an optometrist here at Mayo Clinic Rochester. And the title of my presentation is If It Was a Snake, It Would Have Bit Me, A Story of a macroadenoma. Learning objectives for today is to recognize the overdiagnosis of glaucoma in eyes with normal tensive optic atrophy, also to recognize the diagnostic challenges of non-functioning or pituitary adenomas or asymptomatic adenomas, and also reviewing, you know, pituitary adenoma presentation removal. Multiple choice question for this. Uh, what is the most helpful differential feature in determining glaucoma versus non-glaucomatous optic neuropathy? Is it rim thinning, pallor, or laminar dots? And to start, I'll begin with a case of a 57-year-old male. He's a male employee involved in purchasing, so he does a lot for us. He presented to Mayo Clinic, our general eye clinic, for just a regular exam. He reported no symptoms, no new symptoms. He was happy with his current glasses. He did have a history of LASIK in the early 2000s. When asked, he didn't know what his previous refractive error was, but he knew he was nearsighted, and he did have a positive family history of glaucoma with his father. Medical history was pretty irrelevant. I will highlight a couple of things. He did have head trauma twice, one in 2006 with a suspension device, and then he did pass out in 2013, and both times he reported to the emergency room and had a normal head CT. Uh, he also had sleep apnea, but he was compliant with his CPAP, and the first time I saw him, he was not currently taking any medications. Exam findings were pretty great. He was seeing 20/20 with his current glasses. We found, you know, a little near-sightedness, a slight change in his prescription, a little astigmatism. Again, seeing 20/20 in each eye. EUMs, confrontations, pupils were all normal. Eye pressure was great. It was 11 in the right, 13 in the left with eye care. Anterior exam, you know, you could see a little, a little dryness. You could see the LASIK flap. Um, looking on the posterior side or posterior segment, his previous exam had reported a CD ratio, um, a little smaller. It was 0.4 over in the right and 0.5 over in the left. I thought both were a little bit bigger. I thought it was about 0.55 in the right and 0.6 over in the left, so left was a little bigger compared to the right. Luckily, we're able to get a baseline glaucoma testing pretty quickly. Um, you can see just a little thinner, maybe on the superior side here in both eyes, more so in the left compared to the right. And then, you know, peripapillary over here, it doesn't have that characteristic characteristic, you know, high um myopic kind of fundus look to it, um, but, you know, with you not knowing his history, what, you know, how nearsighted he was, he's like we can't see parapapillary atrophy in those high myopes. Visual fields, if you remember, he was thinner on the superior side, and that could be corresponding to this, you know, early inferior nasal step over on the right and maybe in, you know, inferior arcuate over on the left. Uh, it is a reliable visual field, but looking at it, I was like, you know, this is a little funky. Let's, you know, even though because it's reliable, let's make sure it's reproducible. So let's have you come back here and do this all again. And so differentials I should have been focusing on, you know, besides just ruling out glaucomas. One, you know, this could have just been physiological. He could have some funny looking optic nerves, you know, visual fields, you know, especially in high myops, I think it's up to 16% of those myops can have visual fields that mimic glaucoma and not have glaucoma. Um, I should have also been thinking about compressive optic neuropathy, specifically a mass affecting the anterior visual pathway, and those are, you know, pituitary adenomas, aneurysms, craniopharyngioma, and meningiomas. Um, a lot of with these with compressive optic neuropathy, we should be seeing pallor. Uh, pallor is a, you know, especially in the absence of cupping because less excavation, uh, you're going to see more excavation in glaucoma compared to a compressive optic neuropathy, and pallor is highly specific. About 90% of, you know, folks with compressive optic neuropathy may have, or, you know, you're going to see pallor 90% of the time in Compressive optic neuropathy, but pallor is pretty subjective. It's kind of, you know, the grade is in the eye of the beholder. Um, and a lot of times too with these patients, you're going to see acute rapid vision loss. You know, most often these patients are going to be seeing 2040, or worse. Other things I could have considered are hereditary optic neuropathies or an ischemic optic neuropathy, but again, my patient was probably too young for that to be high on my differential. Uh, his follow-up, uh, I requested 3 to 4 months, of course, with his schedule, my schedule is closer to 6 months with a little bit of probing. Um, he did report noticing more blind spots in his vision and more trouble driving at night. Otherwise, he said he was doing just fine. Visual acuity was still good. It was 20/20 in the right, 2025 in the left. Pupils were reported to be normal and central corneal thickness was thin, but with his history of LASIK, that's totally expected. Eye pressure was still great. It was 11 in the right, 16 over in the left with Goldman appplanation. Uh, so looking at structure, you know, repeat RNFL and ganglion cell analysis, pretty similar, a little thinner on the superior side, still thin on the temporal side. Uh, but where, you know, sitting outside the room, my stomach drops looking at this visual field, being like, oh my gosh, this is very obviously like bitemporal hemianopsia, you know, worse than the left compared to the right. Um, you know, still maybe with some of those nasal, you know, nasal changes, but not so much compared to the first time I saw him. Also at this visit too, I was able to get funnis photos and looking at this, you know, and not during exam and kind of like flitting through everything, um, you can see some of that that temporal pallor worse here in the left compared to the right. And so bringing all this information into the patient, I'm just like, hey, you know, I think there's something going on. We need to get imaging. He's like, Well, doc, you know, I've had imaging before. I've had it in 2006 and 2013. They said everything was normal. Are you really sure I need to have this done again? He's like, I'm, I'm kind of a busy guy. I'm like, you know what, yes, unfortunately you do have to do it. And luckily he did. Unluckily we did find a 51 millimeter macroadenoma. Um, so after, you know, receiving a page from radiology and then calling the patient about next steps, I contacted our front desk and they did an awesome job. They actually got this patient scheduled to see a neurosurgeon just a week later, and he confirmed, you know, a 51 millimeter pituitary adenoma, and he thought, you know, talking to the patient, this is probably a non-functioning tumor because his patient didn't have any symptoms. He thought he was doing just fine. But a few days later, we did get labs that showed high prolactin and low growth hormone. Um, and the surgeon was really great to, to chat with me, you know, asking me, I asked some questions and be like, you know, this is a really big, big tumor. Um, how long has this been going on for? It's like, do they grow pretty fast? Is it pretty slow? He's like, you know, unfortunately, this patient did have this for a while. Um, his prior CTs that he had during, you know, um, His head traumas, you know, 2006 and 2013, you know, they were, you know, the pituitary tumor was present in both, but it was, you know, overlooked. They were looking for, you know, bleeds or head trauma rather than a mass. Two weeks later, this was actually completely removed via the transhenoidal approach, and this, you know, Dr. Wagner touched on this already. This is the gold standard. We access that tumor through the nasal cavity into the sphenoid sinuses. It's considered minimally invasive. Goals of the surgery are to eliminate the mass, normalize hypersecretion, and then eliminate recurrence. Uh, pituitary tumors, these account for 10 to 15% of all intracranial masses. Prolactinomas or and non-functioning adenomas are the most common are the ones you're going to see most often, uh, and they are classified by size. Microadenomas are going to be less than 10 millimeters and macroadenomas are going to be greater than 10. Um, and that, um, pituitary gland, it sits, it's surrounded by that sphenoid bone, the celeursica. Um, so when we have expansion, you know, because it sits inferior to the hypothalamus and the optic chiasm, as that tumor expands, it's going to expand upward into that chiasm. And for these, it's important to evaluate for complete, uh, pituitary function, um, so knowing exactly what type of, you know, if it is hypersecreting, um, getting those labs to, for endocrinology and neurosurgery because they work really close together on, on, uh, on therapy. Vision loss occurs in about 32 to 70% of cases with these chiasmal syndromes. Um, sometimes it's the initial or only symptom, especially in the non-functioning tumors or the tumors that lack those endocrine symptoms. Uh, most often, we're going to see those visual field defects, you know, temporally. It's incongruous, uh, hemianopsia with most often a corresponding vision loss. Again, the optic chiasm sits about 10 millimeters above, you know, the pituitary gland. So as that presses up or expands upward, it's gonna compress on those nasal hemiretinal fibers. Luckily, there's a high treatment rate of success, about 95% of these patients will have improved visual fields and over 50% will have complete visual recovery, which is great. And so our patient had a prolactinoma, um, and these account for, you know, a little less than 50% or half of pituitary adenomas. If you remember back to your anatomy courses, prolactin, that hormone stimulates lactation, so hypersecretion of prolactin will cause infertility and gonadal dysfunction. And women will see amenorrhea or glaerrhea, so these are usually diagnosed as small because women will have changes in their menstrual cycle. They'll be producing breast milk when not pregnant or currently breastfeeding. Men, unfortunately, these tumors have a tendency to be large at diagnosis, and I think it's because men have a tendency of underreporting these symptoms like impotence, infertility, and decreased libido, libido. In both men and women, you're gonna see low bone density. You know, so thinking back to my patient, um. You know, I was so focused on glaucoma, glaucoma being asymptomatic, especially in early to mid stages, having a family history, myopic COPD, you know, maybe a little thinner on the superior side corresponding to those, you know, inferior changes. I was so focused on glaucoma that I missed these red flags. And it also made me think too, you know, looking at these fundus photos, you know, if I didn't have those visual fields that were kind of really highlighting that bitemporal defect, you know, would I have also looked this, you know, temporal pallor worse than the left compared to the right, and it made me think too, you know, to this Oates study back in 2006, so almost like 20 years ago. Um, where they looked at, you know, disc hemorrhages, and 16% of the time us as clinicians were able to, to see, you know, a disc hemorrhage, you know, during our clinical exam. However, 84% of these hemorrhages were actually detected by photograph only, and I was wondering, it's like, is there a similar, you know, study, you know, on disc pallor. Where I didn't find an exact similar study. I did find a couple of cool ones. This is an old study from 1980 with Trobe et al. and this is where he got three observers, all academically based. Two were glaucoma specialists and one was a neuro-ophthalmologist. And they had these observers look at multiple eyes, and they found that 13 of 29 eyes, or 44% of eyes, were actually misdiagnosed as glaucoma when they had a neuro-ophthalmic disorder. 10 of those 13 eyes were actually a compressive optic neuropathy secondary to a tumor. And when they had the observers look at 6 eyes that were misdiagnosed, again, they actually found pallor was present in all of those cases, but again, it was, it was overlooked, you know, pallor is subjective. Um, and another, um, highlight of the study is that the only significant observer errors that we, you know, they overdiagnosed glaucoma because none of the 32 eyes with glaucoma were incorrectly identified. You know, a more recent study from 2017 by Diaz et al. uh, took one neuro-ophthalmologist and one glaucoma specialist, and they had him look at a lot of eyes. They actually gave him, uh, retina photographs in visual fields, you know, 101 eyes with non-glaucomatous optic neuropathy and 42 eyes with normal tension glaucoma. And they found that 12% of glaucoma were misdiagnosed as neuro-ophthalmic disorders, whereas 25% of neuro disorders were diagnosed as glaucoma. So again, glaucoma is overdiagnosed in, in most cases. And so back to our patient, um, he followed up 4 months with our wonderful neuro ophthalmology department. He reported improvement in his central and peripheral vision. He denied any double vision before and after surgery. Visual acuity was great, 20/20 in each eye. Pupils were reported to be normal. Color vision was good in the right eye, but it was decreased over in the left. Um and eye movements, there was, you know, recorded a superior in AB duction limitation. It was pretty mild though, luckily. Scans looking good. It's still thinner on the superior side, but we did have some improvement in that temporal, temporal thinning, that temporal compression. Visual fields were much better. I kind of like to look at it this way. So, uh, before tumor removal, this is the right eye, tumor removal is on the, the left eye or the left side, and then after removal is on the right. Left eye looks beautiful. And I also saw this patient back. So, you know, I was following him as a glaucoma suspect before, so 6 months later, I saw him again, had him do visual fields, which were improved. That right eye looked pretty much normal. Left eye, you know, that temporal depression is looking, looking great. Uh, he reported a significant improvement in his vision, again, seeing 20/20 and eye pressures were 15 and 15. And I kind of, you know, chatted to him or really probed. I was like, you know, what, like, how long do you think you've had this tumor? It's like, you know, it was there in 2006 is when it kind of started. You know, it's a functioning tumor. You had hypersecretion, so it's like you had to have symptoms. It's like, do you, could you pinpoint exactly when he, when it started? He's like, you know, Jackie, I've, I think I've been dealing with this for so long, unfortunately, I just thought it was my normal. It's like, yeah, I've been tired and, you know, I had decreased libido. Now that the tumor is removal, it's like I'm I'm have more energy. I want to go to the gym, and he's like, I'm, I'm feeling better, uh, but he couldn't tell me exactly when this may have all started, especially since he had no changes in vision, headaches, double vision. He was like, I was, I felt like I was pretty normal. So looking into the future with his patients, you know, glaucoma and a macroadenoma can coexist. He has, you know, certain risk factors that put him at higher risk for developing glaucoma. So him and I decided, you know, even neuro neuro-ophthalmology is going to continue to follow him, but we'll keep on checking in regularly and monitoring visual fields and OCTs. If he does have glaucoma, we can start him on treatment here in the future. Um, so this patient did kind of change how I looked at my normal tension suspects, you know, we've all, we all learned, you know, that our NTG patients will, you know, 14, 0 to 14%, um, depending on the study you read of these patients can have, you know, an intracranial tumor. And so I, I think I'm going to be a little, quite a bit more suspicious of these patients because you always think like, oh yeah, I'll be, I'll be, I could tell, I would, I would know, um, but I didn't, you know, it was overlooked, especially the first time. Um, so patients who are around 50 years of age or younger, uh, I'm going to be very highly suspicious, especially if I see a strange optic nerve, checking color vision in these patients just to monitor if one eye is going to have a deficit compared to the other, uh, checking for an APD myself, you know, our techs do a great job. They catch a lot of these, but again, these can be really subtle, uh, and then really being hyper-aware of both visual field defects that are respecting that vertical midline, um, you know, we could still have some that You know, give us that false sense that of, uh, that this is, you know, maybe glaucoma rather than, you know, a neuro-ophthalmic disorder, uh, but really paying attention to that vertical midline and then pallor. Again, it's subjective, but being hyper-aware that it could be present in these patients. Uh, lastly, back to our multiple choice question, what is the most helpful differential feature in determining glaucoma versus non-glaucomatous optic neuropathy? Hopefully, you know, it's pallor. Here are my references. Thanks for listening to me. Does anyone have any questions or comments? Before we start our day. Hi Jackie, this is John. Um, I thought this was a great presentation. I'm glad you, um, kind of really didn't let this, this go, and you know, you repeated the visual field, and then, you know, obviously you diagnosed this very important case. You know, we've seen cases where it comes in way, way later, um, and then at that point it's, it's almost too late. It's a nice job there. Um, I think one other comment I want to say is, um, you used OCT and you kind of looked at the RNFL. I actually think the ganglion cell layer analysis is actually super helpful in these patients. Because what you're going to see is you're going to see nasal bi-nasal thinning of the ganglion cells in both eyes, and then that's a tip-off because essentially with um these compressive lesions affecting the chiasm, you get thinning that respects the vertical meridian, and with glaucoma, you get thinning in the ganglion cell that respects the horizontal meridian. So if you get any ganglion cell layer thinning, if it's binasal, then you're thinking chiasm, and if it's homonymous, then it's going to be kind of optic tract LGN. So I always look at the RNFL, but I, I also look at the gambling, so I think those are super, super helpful. Yeah, great point. And then, uh, compression can cause a little bit of cupping, and so I, we've definitely seen a lot of these patients get kind of mistaken, as you said, pallor is super hard to see, especially if they've got cataracts that are kind of making the nerve look a little bit more orange, um, but that OCT is super, super helpful, right? So I think field's OCT and of course looking for pallor, but it's, I agree, Jackie, it's super hard, yeah. Yeah, unfortunately, it's like I know, you know, I look back and I'm like, you know, how long was this overlooked by, you know, just regular eye exams because we were seeing this patient, you know, all of us ODs and MDs, you know, how long has this been present, and I'm like, oh, you know. I'm glad you found it. Um, you know, you really saved his vision in terms of, you know, otherwise, you know, they can have so much fuel loss and then restrictions on driving, all these things. So nice job. Thank you. All right. Published September 18, 2025 Created by
