Dear colleagues,
I’m sure that many of you are at the AAO meeting, but I was hoping I might get some thoughts about this patient.
She is a 37 year-old Asian female who I first saw In July 2023. at that time she had had a primary resection of an anterior clinic meningioma. a review of her MRI showed the tumor, causing upward displacement of the optic chiasm and lateral splaying of the pre-chiasmatic optic nerves. At the time I saw her, she had had a follow up MRI scan showing a small recurrent anterior pituitary fossa meningioma that was medial to the right internal carotid artery. Although it did not seem to be compromising the optic nerve it was anatomically very close.
Her exam showed vision of 20/25 in the right eye and 20/30 in the left. She had optic atrophy in the right eye with an afferent pupil defect and a fairly modest nerve fiber layer visual field depression. There was also thinning of the retinal nerve fiber layer on the OCT. There were no deficits on the left side. When I saw her in October 2023, she was stable.
at the time of her next visit in May 2024 things looked relatively stable, except that the visual field in the right eye showed an increase in the density of the inferior hemi field depression that also extended into the supero-temporal quadrant off the blind Spot. The MRI showed an increase in the size of the residual pituitary fossa meningioma with extension into the supra seller space and the area of the right optic nerve. At that time even though her visual acuity, color vision, and OCT in the right eye was stable I suggested strong consideration for re-operation. That did not take place by the time I saw her three months later because she was pregnant, but had miscarried.
I did not see her again until June of this year and she had not yet had a re-operation for this tumor and despite good vision, her visual field was declining and again reop was recommended.
I saw her last week, which was about three weeks following re-operation of the tumor and she is now NLP in her right eye with a non reactive pupil. There was also noted some visual field changes in the left eye now. visual acuity remains good in the left eye, but there is some infra temporal depression on the visual field. Her one day, postop MRI scan showed the right frontal temporal craniotomy with resection of the right para sellar/tuberculum meningioma. The intracranial optic nerves and optic chiasm are normal and there was no ischemic infarction or mass effect. because she was aware of the visual field change and it looked different than the preoperative visual field, I put her on 60 mg of prednisone.
I’m going to see her again this week, but I am concerned that she will continue to lose the vision in her left eye. Based on the information I have (although waiting to talk to the neurosurgeon), I’m not sure why she would be losing vision on the left side and what more I can do to help prevent it?
sorry for the long post, but I wanted to try and provide as much information as I could. Again, I greatly appreciate thoughts and recommendations
Enjoy the rest of your weekend,
Andy