Visual Outcome of Patients… Tagoe N.et.al 8 9 5 ORIGINAL ARTICLE Visual Outcome of Patients with Pituitary Adenomas Following Surgery and Its Contributory Factors at a Tertiary Hospital in Ghana Naa Naamuah Tagoe1*, Vera Adobea Essuman2, Patrick Bankah3, Thomas Dakurah4, Vincent Kwaku Hewlett5, Josephine Akpalu6, Thomas Akuetteh Ndanu7 OPEN ACCESS ABSTRACT Citation: Naa Naamuah Tagoe, Vera Adobea Essuman, Patrick Bankah, Thomas Dakurah, Vincent Kwaku Hewlett, BACKGROUND: Craniotomy and transphenoidal microsurgery Josephine Akpalu, Thomas Akuetteh are surgical options for treatment of pituitary adenoma at Korle Bu Ndanu. Ethiop J Health Sci. Teaching Hospital(KBTH). Despite major advances and reported 2018;29(1):895. doi:http://dx.doi.org/10.4314/ejhs.v29i1.11 success rates of transphenoidal resection globally, paucity of local Received: May 23, 2018 data regarding visual outcome of either procedure exists. We Accepted: June 27, 2018 Published: January 1, 2019 evaluated the visual outcome of patient with pituitary adenoma Copyright: © 2018 Hailu Abera Mulatu following surgery in a tertiary hospital in Ghana. This is an open access article distributed under the terms of the Creative Commons METHODS: This is a prospective study of 18 of 45 consecutive new Attribution License, which permits unrestricted use, distribution, and patients with pituitary adenoma seen from November 2010 to July reproduction in any medium, provided the 2013 at Korle-Bu Teaching Hospital(KBTH), Accra, Ghana. Sixteen original author and source are credited. Funding: Korle Bu Teaching (88.9%) of the 18 had surgery by transphenoidal route and Hospital,Accra, Ghana . 2(11.1%) by craniotomy. All patients had macroadenoma (tumour Competing Interests: The authors declare size >1cm) and histological confirmation of diagnosis. Pre-operative that this manuscript was approved by all authors in its form and that no competing and post-operative visual acuity and its relationship to tumour size interest exists. and duration of symptoms before diagnosis were evaluated. Affiliation and Correspondence: 1 RESULTS: Data on 18 patients aged 33-60 years, mean (SD) Eye Department, Korle-Bu Teaching Hospital , Accra, Ghana 45.9±8.5, was analysed. Eleven (61.1%) were females.Visual blur, 2Ophthalmology Unit, Department of 15(83.3%), and headache,13(72.2%), were predominant presenting Surgery, School of Medicine and Dentistry, College of Health Sciences, complaints.Common neuro-ophthalmic signs included unilateral or University of Ghana, Accra, Ghana bilateral optic atrophy, 17(94.4%), Relative Afferent Pupillary 3Neurosurgical Unit, Department of Defect (RAPD) in 8(44.4%) and impaired colour vision in 32 of Surgery, School of Medicine and Dentistry, College of Health Sciences, 36(88.9%) eyes. Preoperatively, 8(22.2%) and 13(36.1%) of 36 eyes University of Ghana, Accra, Ghana were visually impaired or blind respectively. Postoperatively, 4Neurosurgical Unit, Department of 6(16.7%) eyes were visually impaired and 17(47.2%) eyes blind. Surgery, Korle Bu Teaching Hospital, Accra, Ghana Blindness was associated with late presentation (p<0.005) and 5Department of Radiography, School of larger tumour width (p<0.036). Basic and Allied Health Sciences, University of Ghana, Accra, Ghana CONCLUSIONS: More than a third of eyes of patients with 6Endocrine Unit, Department of pituitary adenoma were blind before and after surgery. Blindness Medicine, School of Medicine and was associated with late presentation and larger tumours. Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana Transphenoidal surgery may be beneficial following early diagnosis 7Department of Community Dentistry, to avoid irreversible blindness/visual impairment. School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana *Email: naanaamuahtagoe@gmail.com DOI: http://dx.doi.org/10.4314/ejhs.v28i5.11 8 9 6 Ethiop J Health Sci. Vol. 29, No. 1 January 2019 INRODUCTION Ethical approval was obtained from the Ethical and Protocol Review Committee of the University of Pituitary adenomas account for 10 to 17% of all Ghana Medical School. Pre-operatively, all the 18 intracranial tumours (1–4), and remain in many patients had clinical (neurological, endocrine and cases undiagnosed since they may be asymptomatic ophthalmic) diagnosis of pituitary adenoma with (4). However, some patients may present with well- confirmation by either computerised tomography defined clinical syndromes due to hormonal (CT) or magnetic resonance imaging (MRI). hypersecretion, including hyperprolactinemia, Patients had surgery either by transphenoidal acromegaly,Cushing’s disease and hyperthyroidism route or by craniotomy. All patients had or with impaired pituitary function due to histological confirmation of their diagnosis. compression of the gland (4). Demographic (age, sex, history of symptoms), Larger tumours with severe supra- and/or clinical (ophthalmic, endocrine, neurologic) and parasella extension may cause severe headache, histopathological data were recorded using a visual compromise and oculomotor nerve palsy predesigned questionnaire. (4,5). Surgery remains the treatment of choice for Ophthalmic evaluation included visual acuity majority of these tumours and the gold standard for (VA) tested using Snellen’s chart. For patients who hormonally inactive adenomas (4). In most of were unable to see the letters at the closest test these tumours, surgery is required for the relief of distance, the following test sequence was used: visual symptoms and prevention of further visual count fingers (CF) at 1 m, hand movement (HM) at deterioration (5). 1 m, light perception (LP) and no light perception The most widely used surgical approach for (NLP). Best corrected Visual Acuity with pituitary adenomas since the 1960s has been the spectacles (BCVA ) was recorded using WHO transphenoidal route, using the operating categories of visual impairment adapted from the microscope. It is the preferred approach for most International Classification of Diseases (9th cases of pituitary adenomas, due to its low risk of revision, 1975), visual status was graded as: complications coupled with good outcome (4–8). (a) ‘Blind’ when visual acuity (VA) was <3/60 Microsurgical transphenoidal surgery has (b) ‘Impaired’ when VA was <6/18–3/60 been the main surgical method employed at Korle (c) ‘Normal’ when VA was 6/6–6/18. Bu Teaching Hospital (KBTH) for pituitary Colour vision was tested using Ishihara adenomas since 2002. Craniotomy is performed for Colour Vision Charts (38 Plate Edition 1994). giant tumours which are inaccessible by the Anterior segment assessment included slit lamp transphenoidal approach. There are, however, no examination (using Topcon ATE-600 2004, Japan), published data in Ghana on the visual outcome of pupil reaction to light and Relative Afferent these patients following transphenoidal resection or Pupillary Defect(RAPD). craniotomy. This study sought to determine the Fundus examination was done using visual outcome of patients presenting at KBTH biomicroscopy with a + 90D lens, indirect with pituitary adenoma after surgery and to identify ophthalmoscope with +20D/ +28D lenses and the factors which may influence this outcome. direct ophthalmoscope through dilated pupils MATERIALS AND METHODS (using tropicamide 1%, and or cyclopentolate 1% combined with phenylephrine 2.5% eye drops). This was a prospective case series involving 18 Visual field (C30-2) was assessed using a consecutive patients diagnosed with pituitary Humphrey visual field analyser (SITA, Carl Zeiss adenoma and treated surgically from November Meditec; Dublin CA.USA, 2005) 2010 to July 2013. Patients who received either Assessment of the size of the tumour was medical or no treatment, as well as those who did done radiologically using Computerised not consent to participation were excluded from the Tomography scan (CT scan) Hitachi Eclos -2009 or study. Magnetic resonance imaging (MRI) Hitachi Airis elite (OPEN). DOI: http://dx.doi.org/10.4314/ejhs.v27i8.11 Visual Outcome of Patients… Tagoe N.et.al 8 9 7 Endocrine evaluation: This included clinical diagnosis was confirmed by CT scan in 15(83.3%) examination of patients by the endocrinologist and of the cases and MRI in 3(16.7%) of them. assessment of anterior pituitary hormones namely All 18 patients had pituitary macroadenoma leutinizing hormone(LH), follicle stimulating (tumour size>1cm), confirmed by neuroimaging. hormone(FSH), 9am serum cortisol, prolactin Out of the 18 patients who had surgery, 16(88.9%) (PRL), triiodothyronine(free T3), thyroxin(free T4), were by transphenoidal route and 2(11.1%) by and thyroid stimulating hormone (TSH). craniotomy. Neurosurgical evaluation: Neurosurgical Duration of symptoms before presentation: The evaluation by the neurosurgeons included history duration of symptoms before presentation ranged and examination of the nervous system: Mental from one day to 96 months with mean (SD) of state, cranial nerves, coordination, motor and 29.9±30.8 months and median of 24 months. Table sensory examinations. 1 shows duration before presentation. Outcome measures: Primary outcome measures studied included Table 1: Duration of symptoms before presentation in 18 patients with pituitary adenoma • visual acuity at presentation • visual acuity after surgery Duration of Number Secondary outcome measures were symptoms (months ) (%) • size of tumour at presentation. 0-6 7(38.9) • duration of symptoms before presentation. 7-12 1(5.6) Statistical data analysis: Data was captured using 13-24 2(11.1) Microsoft Access and analysed using Statistical >24 8(44.4) Package for Social Scientists(SPSS) Version 16.0. Continuous numeric data were summarized as Presenting symptoms and signs: Visual blur (15, Mean and Standard deviation (SD) and categorical 83.3%) and headache (13,72.2%) were the data as percentages (%). Results were presented as commonest presenting complaints.The commonest frequencies, tables and charts. To prove significant neuro-ophthalmic signs encountered were RAPD in outcomes, t-test was used to compare mean levels 8(44.4%) and unilateral or bilateral optic atrophy in of visual acuity between right and left eyes. Mann- 17(94.4%) of which 10(55.6%) were bilateral. Whitney Test was used for establishing significant Impaired colour vision occurred in 32(88.9%) of association between, duration before presentation the 36 eyes (Table 2). and, visual acuity, and tumour size. Chi-squared was used to compare proportions, at 0.05 Pre- and post-operative Best Corrected Visual significant levels. Logistic regression analysis Acuity (BCVA): was used to establish significant association Pre-operatively, 21(58.3%) of the 36 eyes were between visual acuity and tumour type and size. visually impaired or blind . Of these, 5(13.8% eyes The association between categorical variables was had visual acuity of No Perception of Light (NPL). determined using Chi-square test while Post-operatively, 23(63.9%) of the 36 eyes were comparison of mean values was performed using visually impaired or blind (Table 3).Post- the one-way analysis of variance (ANOVA) test operatively, out of 36 eyes, visual acuity improved for more than two means. in 9(25%), worsened in 10(27.8%) and remained the same in 17(47.2%). RESULTS Considering visual acuity in 32 eyes of the 16 Forty-five consecutive patients were diagnosed patients who had transphenoidal resection, vision with pituitary adenoma during the study period, but improved in 21(21.9%), worsened in 10(31.2%) data on 18 patients who had surgical treatment was and remained the same in 15(46.9%) eyes. Eight analysed. The ages of the 18 ranged from 33-60 (25%) eyes had pre-operative visual acuities of years with mean(SD) = 45.9±8.5. Eleven (61.1%) Counting Fingers (CF) to Perception of Light (PL), were females and 7(38.9%) males. Neuroimaging and 4 eyes had visual acuity of NPL (Table 3). Two DOI: http://dx.doi.org/10.4314/ejhs.v28i5.11 8 9 8 Ethiop J Health Sci. Vol. 29, No. 1 January 2019 of 8 eyes with pre-operative visual acuity ranging Table 2: Presenting symptoms and signs in 18 patients from CF to PL had improved visual acuity after with pituitary adenoma surgery. This included one patient with pre- operative visual acuity of CF in one eye improving Symptoms / signs Number (%) by 3 Snellen lines to 6/24 and the other with visual Ocular Symptoms acuity of Hand Motion (HM) improving by a line to Visual blur 15(83.3%) Counting fingers(CF). None of the patients with Ocular pain 4(22.2) Diplopia 3(16.7) visual acuity of NPL had improvement in visual Ocular signs acuity after transphenoidal surgery (Table 3). Colour vision impairment (Out 32(88.9) of 36 eyes) Optic atrophy 17(94.4) RAPD 8(44.4) Strabismus 2(11.1) Optic disc swelling 1 (5.6) Red eye 1 (5.6) Non ocular symptoms Headache 13(72.2) Irregular menses 7(38.9) Ammenorrhoea 4(22.2) Non Ocular signs Galactorrhoea 3(16.7) Cranial nerve palsies 0 (0.0) Table 3: Preoperative and postoperative monocular visual status of 18 patients with pituitary adenoma. Preoperative visual status Postoperative visual status n (%) n (%) Visual status Right eye Left eye Total Right eye Left eye Total eyes (n=18) (n=18) (n=36 ) (n=18) (n=18) (n=36) Normal 9(50.0) 6(33.3) 15(41.7) 6(33.3) 7(38.9) 13(36.1) Visually impaired 2(11.1) 6(33.3) 8(22.2) 2(11.1) 4(22.2) 6(16.7) Blind 7(38.9) 6(33.3) 13(36.1) 10(55.6) 7(38.9) 17(47.2) Total 18(100) 18(100) 36(100) 18(100) 18(100) 36(100) n = number, %= percent One of the patients who had craniotomy had Visual field status: The commonest pre-operative improved vision whilst the other had a drop in visual field defects encountered in this series were visual acuity by a Snellen line in one eye (Table 4). unilateral or bitemporal hemianopia 10(55.6%). Time between onset of symptoms and presentation Other visual field defects were superior at the hospital was longer in the blind patients. quadrantanopia 2(11.1%), total field loss 2(11.1%) This was found to be statistically significant and Junctional scotoma 1(5.6%). Visual field test (p<0.005).Considering the eyes, there was a was not performed in 3(16.6%) patients because significant association between duration of the best corrected visual acuity in their better eyes symptoms and blindness in the right eye (p<0.020) ranged from CF to NPL. Post-operatively, visual but not in left eyes (p<0.518). There was a field test results could only be obtained in a few significant association between duration of patients; hence, the pre-operative and post- presentation for the blind eyes and the normal operative results could not be compared. The (p<0.004) or visually impaired eyes. (p<0.002). majority of the patients could not do the test due to poor vision and financial difficulties. There was no DOI: http://dx.doi.org/10.4314/ejhs.v27i8.11 Visual Outcome of Patients… Tagoe N.et.al 8 9 9 significant association found between age of eyes were more likely to remain visually impaired patient and visual status at presentation (p<0.465). after surgery (p<0.002). In the left eye, however, Tumour size, the widest dimension of tumours, there was no significant association found between was assessed. This ranged from 28.0mm to tumour width and visual impairment before 79.4mm, mean (SD) = 39.7 ± 1.3. (p<0.565) or after (p<0.537) surgery. Larger tumour width was associated with visual impairment in right eyes (p<0.036). These Table 4. Pre and post-operative best corrected visual acuities in 18 patients with pituitary adenoma Serial number of patient Preoperative Post-operative Preoperative Postoperative visual acuity visual acuity visual acuity visual acuity Right eye Right eye Left eye Left eye 1 6/5 6/5 6/36 6/36 2 6/12 6/12 6/36 6/36 4 CF NPL 6/36 CF 7 6/9 6/9 HM CF 10* 6/36 6/60 NPL NPL 18 6/18 NPL NPL NPL 30 6/36 NPL 6/5 NPL 37 NPL NPL 6/9 6/12 40 6/5 6/5 6/36 6/18 41 NPL NPL CF 6/24 42 6/9 6/6 6/24 6/60 49 CF HM 6/9 6/6 56 CF CF PL PL 62 6/5 NPL 6/5 6/12 65 6/12 6/6 6/36 6/9 66* 6/12 6/24 6/12 6/9 67 HM HM 6/18 6/18 68 CF CF NPL NPL *Patients who had craniotomy CF= Counting fingers, HM= Hand motion, NPL= No perception of light, PL= Perception of light DISCUSSION This finding is higher than that reported in a series by Turner HE et al which showed 39.3% presenting with Surgery is the treatment of choice for the majority of primary symptom of impaired visual acuity (9) but pituitary adenomas and the “gold standard” for corroborates the findings from a study in Kenya (10) hormonally inactive adenomas (1,4). The presence of which reported visual impairment of 87.7%. visual deficit is the major indication for surgery by The visual outcome after a trans-sphenoidal either the transcranial or transphenoidal route (7). procedure is usually excellent (4,5,8,10–12). Severe Transphenoidal surgery however is the most visual defects secondary to optic nerve or chiasm common and successful approach due to its low risk of compression can regress or resolve completely (11). complications and applicable to majority of the cases Most of the improvement occurs during the first few (1,4,5,8). In most of these tumours, it is required for the days or weeks following surgery (11). Pre-operatively, relief of visual symptoms and prevention of further 58.3% of 36 eyes in this study were visually impaired or visual deterioration (4,5). blind. This increased to 63.9% after surgery. This high In this series, visual deterioration was the proportion of eyes blind or visually impaired, is not commonest mode of presentation in 83.3% of the surprising considering the fact that a greater percentage patients. Visual deterioration was confirmed on ocular (94.4%) of patients presented with unilateral or bilateral examination. The majority (58.3%) of eyes were found optic atrophy as opposed to 29% in other studies (10) to be either blind or visually impaired at presentation. with better surgical outcome. DOI: http://dx.doi.org/10.4314/ejhs.v28i5.11 9 0 0 Ethiop J Health Sci. Vol. 29, No. 1 January 2019 Close to half of the patients maintained their prolonged duration of symptoms before presentation in visual acuity, about 20% improved by 1 to 3 Snellen our patients, post-operative visual field testing (if done) lines whereas about a third worsened. This study could have demonstrated little or no recovery in those showed lower improvement than in other studies, i.e. who had pre-operative visual field defects. 78% (8), 71% (11), 71. 5% (10) and 76.9% (13). Only Unfortunately, post-operative visual field test results one patient with pre-operative visual acuity of CF were obtained in only a few patients. Therefore, the pre- improved to 6/24. None of the patients with visual operative and post-operative results could not be acuity of NPL had improvement in visual acuity after compared to corroborate these findings. transphenoidal surgery. This differs from the findings in The choice of transphenoidal approach as Elgamal et al’s (11) and Ayub et al (5) in which visual opposed to craniotomy is determined by a number of acuities of patients with NPL and CF improved after factors including degree of suprasella extension, tumour surgery. This disparity may be due to the late consistency, brain invasion, cerebral edema and presentation, with over a third of the patients in this encasement of the optic apparatus (10). This study study presenting after 24 months as opposed to Ayub’s included only two cases of pituitary adenoma who had (5) study in which the patients whose visual acuities craniotomy compared with 16 cases who had improved from NPL had been blind for only 2 to 10 transphenoidal resection. It was, therefore, not possible days. This strengthens the need for early diagnosis and to statistically compare the two surgical options. Kiboi surgery in patients with pituitary adenoma. et al (10) in their series,where 45% of the patients had Visual field defects are recognized presentations transphenoidal and 55% transcranial surgeries, found no of pituitary adenoma (11,14). The typical visual field significant difference, statistically, between these two defect pre-operatively is bitemporal hemianopia (15). approaches. A larger number of cases of craniotomy Other visual field defects encountered in other studies will be needed in this study population to draw any include superior quadrantanopia, homonymous meaningful conclusion. hemianopia, junctional scotoma, total field loss, central Visual presentation of pituitary adenoma varies scotoma, arcuate scotoma and monocular visual depending on the size of the tumour and its proximity to constriction (16-18). optic pathway (11). Large tumour size and closer The type of visual field defect depends on the proximity to the optic chiasma in this series may also be relation between the optic chiasm and the tumor itself responsible for poorer postoperative visual outcome. (16). Bitemporal hemianopia is due to the anatomical Macro adenomas are characterised by a higher compression of the optic chiasm, where the crossing frequency of neuro-ophthalmological symptoms and nasal fibers of each optic nerve occurs (15). In an poorer response to surgical therapy (3). Whereas micro anatomical post-fixed chiasm (tumour is placed more adenomas may have negligible effect, macro adenomas anterior to the chiasm) visual field defects such as can cause severe impairment of visual acuity, colour central scotoma, arcuate scotoma and monocular visual vision and visual field defects by their compressive constriction can occur. On the contrary, if the tumor effect on the optic nerves and chiasma (26). compresses the optic tracts or there exists a pre-fixed Optic atrophy was present in 94% of cases in this chiasm, a homonymous hemianopia may occur (16,17). study as opposed to 13% in Ayub’s (5). It is a sign of This study demonstrated some of these defects pre- long standing chiasmal compression from pituitary operatively, with unilateral or bitemporal hemianopia macro adenomas and is responsible for poorer being the commonest. Other factors that influence the prognosis following surgery (5). It results from type of visual defects include the size of pituitary secondary retrograde axonal degeneration as the tumour adenoma (6, 19,20) and tumor volume (21). grows upwards (5,11). Tumour growth upwards towards Some studies have demonstrated recovery of the optic chiasma is the most frequent extrasella visual function including visual field defects post- extension of pituitary adenoma(3). Macro adenomas operatively, with a shorter duration of symptoms, with significant suprasella extension have been younger age and a better preoperative Best Corrected correlated with significantly worse postoperative Visual Acuity found to be associated with better outcomes(3,5,10). postoperative recovery (7,22). However, others have Tumour consistency, extent of suprasella shown little or no recovery of the visual fields (23,24), extension and brain invasion are some factors that especially in patients with severe optic atrophy, influence the choice of transphenoidal resection as suggesting a direct relation between the degree of optic opposed to craniotomy. Firmer consistency of tumour atrophy and visual recovery (1,23,25). Given that optic has been documented to pose a challenge to adequate atrophy was a major presentation, coupled with resection of suprasella component of large pituitary DOI: http://dx.doi.org/10.4314/ejhs.v27i8.11 Visual Outcome of Patients… Tagoe N.et.al 9 0 1 tumours (5,10). This, however, could not be confirmed after surgery. Blindness was associated with prolonged in our study because the tumour consistency was not duration of symptoms and larger tumour size. The assessed. commonest clinical presentations were visual blur and Duration of symptoms before presentation optic atrophy. Transphenoidal surgery may be beneficial ranged from one day to 96 months with a median of 24 following early diagnosis to avoid irreversible blindness months. This corroborates findings by Marcus et al or visual impairment. (12), but differs from Elgamal’s (11). The extensive time interval between onset of visual symptoms and REFERENCES diagnosis has been noted in many studies (10,11,13). 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