 The next presenter is Bobby Kim, who is a neurosurgery resident. He's been with us for a couple of weeks, and he's going to be doing, as we usually recommend, a surgically-oriented neuroanoptomic presentation patient that he saw with Dr. DeGree. Morning, everyone. My name is Bobby Kim, one of the first-year residents from neurosurgery. This morning, I'm going to talk about vision loss after pituitary tumor resection through the transphenomenal approach. So PK is a 43-year-old male who presented with progressive left eye vision loss over two years and new right eye photosensitivity. Approximately two years ago, his vision problems started off as difficulty with distance vision in his left eye. And six months ago, he was diagnosed with myopia and astigmatism, but his left eye vision was unable to be corrected. At that time, his visual acuity was 20 out of 30 in the left eye and 20 out of 15 on the right. And approximately a month ago, he could only see shade movement and light in left eye, but he couldn't see distant features except temporally with his left eye. And about a week prior to his presentation, he started developing photosensitivity in his right eye as well. He didn't have any double vision, no painful eye movements or flashing lights or halos. His past medical history was not significant with the exception of latex surgery in 2001 and trauma to his left face in 2011, but there was no ocular injury. So these are his eye exams on his initial presentation at the clinic. His visual acuity on the right eye was 20 out of 15, but his left eye, he was only counting fingers of face temporally. He had an APD on the left in his visual field exam. On the right, he had superior temporal field defect, as well as a little bit of inferior temporal field deficit as well. On the left, he had nasal centrosiegel scotoma. And on OCT, he has some inferior thickening on the right eye. And on the left, he has some temporal atrophy. So these are his images. So concerning for space-occupying mass lesion, MRI of the brain and orbit were ordered, which showed cystic, peripheral-enhancing lesion in the cellar, which was likely either a Rathke cleft cyst or a cystic pituitary macroradnoma. It had some mass effect on the optic chiasm and pre-chiasmatic optic nerves greater on the left than right with associated signal abnormality of the left optic nerve. So this is the coronal post-contrast image showing the about 2 centimeter macroradnoma or pituitary tumor at this point, kind of having a compressive effect on the chiasm. And this is the stir image. If you look closely, there's some signal abnormality in the pre-chiasmatic optic nerve on the left. And this goes all the way to involve the anterior portion of the optic nerve. So based on his symptoms and the image findings, this was consistent with junctional scotoma, which is a scotoma in the ipsolateral eye and superior quadrantinopia in the contralateral eye. You can get these symptoms by compression of the structure called Neovol brand, which is basically a loop of inferior nasal fiber that crosses the chiasm and travels up the contralateral optic nerve for a short distance before traveling in the optic tract. So any pituitary tumor or mass lesion that's compressing on the inferior portion of the pre-chiasm can produce something like junctional scotoma. So referral was made to neurosurgery. So at the time of initial evaluation, he didn't have any gynecomastia. No heat or cold intolerance, no change in libido. On exam, he was neurologically intact, except for excision. So a patient underwent TSRPT, which stands for Transfinal Inversection Pituitary Tumor, with fat and fascia graft packing. Those are done to prevent CSF leak. Post-operatively, the path came back as non-secreting cystic pituitary macronoma. He was in compensated DI, but in general, he was doing fine clinically. Post-op, his right eye vision worsened, actually, especially with the colors. He quoted that blue and red are more neon. He also had more photophobia. And it was discharged home on post-op day three. So on his follow-up visit, his visual acuity and his right eye actually worsened significantly. On the right eye. He was scared out of his core. What's that? I'm sorry? He was scared out of his gourd. That increased vision in the right eye. Possibly. I've had some of these patients go through, including one who was a neurosurgeon going through this. I was getting calls five times a day. Am I a good eye going to go? Everybody recognized, these are the patients who really need hand-holding, because this is scary stuff. You've got one eye that you've lost vision, and now your good eye started to impact it. This is a real gut-crush. Oh, he seemed pretty stoic to me at the time. He was like, my right eye is getting worse. I didn't show up to the neurosurgeon, but I can tell you that. So his visual acuity on the right eye was 20 out of 100, compared to 20 out of 15. It was still counting fingers that faced temporally. His color vision on the right eye was basically zero. His S.E.R.R. test was zero, three, and zero of six. And on the fundus exam per note, it looked a little full, question mark. Maybe slight blush. It still had him very thickening. So concerning for what's going on in there, another brain MRI was ordered that showed increased signal abnormality in the chiasm. All this stuff right here is fat packing with fascia. And then there's still signal abnormality in the left pre-chiasmatic optic nerve. Left optic nerve, there's still signal abnormality. And there's new signal abnormality in maybe right optic nerve as well. And again, all this stuff is fat. So we were concerned for a compressive effect on the chiasm from the fat graft. So a patient was readmitted to the hospital for a return to OR for fat graft removal. Hit it fine. From my conversation with the fellow who was involved in the case, he didn't believe that the fat packing was any more significant than all of the other pituitary surgeries that he was involved in. On post-update one, however, his right eye visual acuity still worsened. He was 20 out of 400 on the left right eye. It was still counting fingers on the left eye. On post-update three, his acuity got maybe a little better or was stable. He was 20 out of 200 to 400 on the right eye and counting fingers on the left eye. And during this time, Dr. DeGray has been seeing the patient pretty much every day. He was discharged home on post-update three. And per Dr. DeGray, we started actually neurology starting him on IV-methylprenasalone, one grand for three days on post-update four, five, and six. But my understanding was that he didn't have any improvement in his vision even after high-dose steroid. So these are his exams on the follow-up visit. His visual acuity was 20 out of 400, which is far worse than his prior two visits. Still counting fingers to face temporally. His fundus exam showed nasal haziness and temporal parlor on his fundus. And this is basically his progression of the right eye visual field, initially involving superior quadrant, upper quadrant here, but then kind of globally involving his visual field, sparing his inferior nasal quadrant there. Additional laps were ordered to rule out any autoimmune or other etiologies, which were basically all normal and negative. His oligoclonal band was negative. His LP, his opening pressure was pretty much normal. And he had normal CSF profile. So there's some literature to gather more information on the incidence of worst-case visual outcome after pituitary surgery and to identify any risk factors, both preoperative, intraoperative, that are associated with worst-ing vision outcomes after pituitary surgery. So in this paper, which evaluated visual outcome in 2,000 eyes following TSRPT, 90% of the patients had a macro adenoma, 97% of which underwent TSRPT, and immediately post-op visual acuity and visual field improved in only 16.3% and worsened in 3.6% of the patients. But in one-year post-op, visual acuity and visual field improved in 93% of the patients, remained static in 5.2% and worsened in 1.3%. So most of these patients do pretty well and their visual acuity and visual field improved to some extent up to one-year post-op. And some of the risk factors that were associated with poor visual outcome was longstanding symptoms, patients who had visual symptoms for more than a year and complete opti-gatrophy on exam. Those were prognosticated factors for poor visual outcome and a shorter duration of visual deficit predicted better outcome. And in this paper that was published in the Journal of Neurosurgery, they looked at 79 patients and they predicted the type of tumor that predicted visual outcome. It was shown that patients with pituitary tumors had the greatest improvement, followed by craniopharyngeoma and meningiomas. And interestingly, no improvement in vision was seen in patients with epidermal tumors, cord dilemma, or U.A. sarcoma. So type of tumor is also important. But all of these papers in literature sort of describe whether the vision improves, remain static or worsens. None of the papers really delved into the mechanisms that may be behind all of these vision loss. So this is an old paper that was published in 1990 from a group in Emory. It was a case series describing 11 patients, but they were sort of trying to come up with predictive factors for vision loss and potential risk factors. So I lost the screen here. So factors that may cause post-operative vision loss, they thought it was these are all real life experience from their surgeries. Direct injury to the optic nerves and or chiasm during tumor removal or devascularization of the optic nerve chiasm from the other here in tumor removal. And this is especially apparent in re-operation or patients who had history of radiation to that area. Also compression from post-operative hematoma, packing of the cell with too much fat or muscle, or direct damage to the optic nerves that comes from fracture of the optic frame and from rigorous retraction. Also prolapse of the optic nerves and chiasm into the empty cell can happen if it's a giant macaradenoma that just kind of falls into the empty cell. And very rarely patients develop cerebral vasospasm, which are of course associated with other neurological symptoms. And the potential risk factors that they identified that may predict the likelihood of visual complications were presence of macaradenoma versus micro, having visual impairment pretty operatively. Weir-shaped tumors that look like bottleneck or dumbbell or history of previous surgery, radiation therapy and use of an intraoperative lumbar, subarachnoic catheter, which we don't do here. It's sort of used to manipulate the stock up and down to get a better resection. So with respect to fat pack, I found one paper that described two patients who had visual loss after transphenotal surgery that was likely secondary to fat packing. After fat packing removal, one patient had total visual recovery right away, and the other patient, he's persistently had chiasmal compression either from intracellular fad or residual tumor. So in conclusion, post-TSRPT vision loss is a rare but serious complication. Immediate postoperative evaluation of vision and neurological status are important and they can direct further management and can lead you down different pathways, imaging, taking the patient back to the operating room, starting the patient on high dose steroid, et cetera. Most common causes of immediate post-TSRPT vision loss were supercell or hematoma, direct damage to optic apparatus, devascularization of the chiasm, overpacking or fracture of the foremen. And whether or not the immediate postoperative vision loss after pituitary surgery improves in long term is unknown. I couldn't find anything. It was seen in the clinic, but I don't know what happened to it. I see him tomorrow. I've been following him daily in the hospital and then every week, so I'll see him tomorrow. Is he still up with you or is he scared? I know he's not still like he's very frightening to you. Things about this case are weird. I mean, we see a lot of pituitary tumors here and his presentation was so classic with that central scatoma high in the sky. It's just like what we teach in textbooks. And usually you do the surgery and everything is great and he had great OCTs before surgery, so I was very hopeful that he would do very, very well. And then immediately afterwards when his vision was going down to the right eye, the radiologist read the scan and showed a compression from the fat pack. And I know no surgery didn't think that it was that much fat pack, but because of that, Dr. Kogel did recommend taking some of the fat out so that it wasn't compressing it so much. And then the thing that's disturbing to me is that he's got, it looks like demyelination in the kaya, something in the nerve. We are working about the labors for auditory optic neuropathy. I thought he had a negative kind of O-antibody, so we're working up for labors. Could he have had ticks and fleas? Two things that would give him two optic neuropathies, but we'll keep you posted. He's a very nice guy. And, but it's good that we have other resources here at Miranda Health with this post-type of visual loss. It's not common. I've never seen anybody have this much trouble after transferring a little type of apocytomy. So having had both a neighbor and a friend who's also a neurosurgeon who went through this and Dr. Greenhouse was talking about and was very stoic to neurosurgery. It's good for neurosurgery to hear this. Scared out of his gourd calling me five times a day. And he got worse after it. He and I had a long debate and this is a very well-known neurosurgeon who ended up with a good career. Oh, he dealt that one. The big debate we had on him is that, his feeling is that in the desire to make sure that we just don't have CSF leaks chronic, which are a big problem, is that we are potentially now over-packing fat in that there's more of this. And his sense, as he reviewed, is that there are more who are starting to get worse for a while before they get better. I just, I don't claim to be an expert, but he and I talked about that and he admitted that it had not been looked at carefully. So is that something called neurosurgery? That's a good question to ask. How much is too much and is our outcome in trying to be 100% certain we don't have CSF leak may be resulting in compressive damage that otherwise could be avoided? Because he said he didn't think that has been well-addressed nor answered in any decent study. No. Would you agree with that? Totally. I've looked at this literature now twice with him and with this guy both. You know, the first one, he did not do anything. He just waited it out and he did great. He did just, he did great, but. Well, but he got a lot of gray hairs. Oh yeah. He didn't get some gray hairs. There was a lot of handful that it all worked out. That's an important question to answer. Yeah. It would be great to know. The problem is, I think you can see from the literature, it's very rare. And so how much. Get the numbers to be able to do that. It's extraordinarily rare. I mean, I've seen a patient with this. It's very, very rare. I think that there's a lot of variability in the anatomy, especially the vascular anatomy, which is not something that is ever evaluated preoperatively. But I think that what's most interesting about this is that his vision loss progressed after the surgery. It wasn't like he just woke up from the surgery with terrible vision. His vision actually worsened after the surgery. All of us in the process got picked. Exactly. And I think that that's why the extensive evaluation. So hopefully, things will improve. Thank you very much. Thank you. Thank you. Thank you.