Neuroradiolog y/Head and Neck Imaging Original Research

Lee et al.
Visual Defects Noted on MRI Examination of Patients With
Pituitary Adenomas

Neuroradiology/Head and Neck Imaging

Original Research
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Visual Defects in Patients With

Pituitary Adenomas: The Myth of
Bitemporal Hemianopsia
In Ho Lee1, 2 OBJECTIVE. The objective of this study was to test the hypothesis that bitemporal hemi-
Neil R. Miller 3 anopsia (BHA) is the most common visual field (VF) defect in patients with pituitary mac-
Elcin Zan1 roadenoma and to assess the degree of optic pathway compression necessary to produce vi-
Fabiana Tavares1 sual defects.
Ari M. Blitz1 MATERIALS AND METHODS. We reviewed the MRI findings and medical records
of 119 patients with pituitary macroadenoma who had undergone formal assessment of VFs.
Heejong Sung 4
We then evaluated the degree of optic pathway displacement caused by the pituitary mac-
David M. Yousem1 roadenoma, as observed on MR images. The classifications of optic pathway displacement
Michael V. Boland 3 included no contact, abutment but no displacement, mild displacement (<3 mm), and moder-
Lee IH, Miller NR, Zan E, et al. ate displacement ( 3 mm). Qualitative analysis classified VFs as normal or as having defects
that were monocular, bitemporal, mixed (bitemporal with additional defects), homonymous,
or nonspecific.
RESULTS. A total of 89 of 115 patients had an abnormal VF. Only one patient had true
BHA. The most common defects were bitemporal or mixed defects (in 49 of 115 patients
[42.6%]), likely because more than just the chiasm is often compressed by the pituitary mac-
Keywords: optic chiasm, pituitary adenoma, visual deficits roadenoma. Classification of optic pathway displacement by the pituitary macroadenoma was
as follows: 23 patients had no contact, eight had abutment but no displacement, 27 had mild
DOI:10.2214/AJR.15.14527
displacement, and 57 had moderate displacement. In 78 of the 92 patients (84.8%) with pitu-
Received February 7, 2015; accepted after revision itary macroadenoma that had contact with the optic pathway, contact was with the optic chi-
April 16, 2015. asm and the prechiasmal optic nerve. Of the 49 patients with bitemporal or mixed defects, 42
had moderate displacement of the optic pathway caused by their tumors.
The opinions and assertions contained herein are the
private views of the authors and are not to be construed
CONCLUSION. BHA is exceedingly uncommon in patients with pituitary macroade-
as official or as representing the views of the National noma. However, although bitemporal and mixed defects are the most common abnormal VF
Institutes of Health. findings, they were found in only 42.6% of patients. Such defects rarely occur if the tumor
1
displaces the optic pathway less than 3 mm from baseline.
Russell H. Morgan Department of Radiology and
Radiological Sciences, The Johns Hopkins Medical

W
Institutions, 600 N Wolfe St, Phipps B100F, Baltimore, hen most neuroradiologists con- ningiomas, craniopharyngiomas, and aneu-
MD 21287. Address correspondence to D. M. Yousem sider the visual field (VF) deficits rysms [2, 3].
(dyousem1@jhu.edu). associated with pituitary adeno- The visual deficits associated with pitu-
2 mas that compress the chiasm, itary adenoma depend on the size, location,
Department of Radiology, Chungnam National University
Hospital, Daejeon, Korea. they automatically think of bitemporal hemi- and hormonal activity of the tumor as well as
anopsia (BHA). This is a VF deficit in which the position of the chiasm as it relates to the
3
Wilmer Eye Institute, The Johns Hopkins Medical all the vision in the temporal fields of both sella turcica [4]. According to a recent study,
Institutions, Baltimore, MD. eyes is lost, leaving only the nasal fields to the tumor volume also affects the severity of
4
Genometrics Section, Computational and Statistical
be perceived. Incomplete bitemporal VF de- the VF defect [5, 6].
Genomics Branch, National Human Genome Research fects are much more common than true Although a previous study of 50 patients
Institute, National Institutes of Health, Baltimore, MD. hemianopsia and are considered by neuro- showed a significant correlation between chi-
WEB ophthalmologists as a sign characteristic of asmal compression and visual disturbances
This is a web exclusive article. chiasmal syndrome, which is usually caused [7], to our knowledge, no MRI-based lit-
by lesions that affect the optic chiasm from erature shows the relationship between the
AJR 2015; 205:W512W518
below [1]. Pituitary adenomas are the most degree and symmetry of extrinsic anteri-
0361803X/15/2055W512 common of all chiasmal syndrome tumors, or visual pathway compression by pituitary
followed by other lesions that cause extrin- macroadenoma and the pattern of VF defects
American Roentgen Ray Society sic optic chiasm compression, such as me- observed in patients. One goal of this study

W512 AJR:205, November 2015

 Visual Defects Noted on MRI Examination of Patients With Pituitary Adenomas
was to test the hypothesis that bitemporal
VF defects, not BHA, are the most common
defect in patients with pituitary macroad-
enoma. We also wished to determine what
degree of optic chiasm compression is nec-
essary to produce such defects and how of-
ten asymmetric visual defects are associated
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with pituitary macroadenoma that asymmet-
rically affects the prechiasmal optic nerves,
optic chiasm, or postchiasmal optic tracts.
Materials and Methods
This retrospective study was reviewed and ap-
proved by the institutional review board of The
Johns Hopkins University School of Medicine.
Because of the retrospective nature of the study,
informed consent was not required for review of
either the medical records or the MR images.
We retrospectively searched our imaging ar-
chive for patients who had pituitary macroadeno-
ma diagnosed by MRI between November 2009
and October 2012. In all patients, at least one di-
mension of the pituitary macroadenoma measured
at least 10 mm. We then reviewed the imaging
findings and medical records of the 185 patients
who were identified using this strategy. Sixty-six
patients were excluded either because they did not
have any VF testing results available or because
they had other underlying diseases, such as stroke,
glaucoma, ocular or intracranial trauma, retinal
artery occlusion, other retinal diseases, amblyo-
pia, or unrelated optic neuropathy, all of which
could affect the results of VF testing. Next, we re-
viewed the clinical findings and ophthalmologic
records of the remaining 119 patients who were
included in the study, including documentation of
VF defects and reported visual complaints.
All VF tests were performed using a Humphrey
Field Analyzer (Carl Zeiss Meditec). Test patterns
were either 242 or 302, and strategies included
use of the Swedish interactive threshold algorithm
or full threshold.
Qualitative Visual Field Analysis
Qualitative analysis of the VF tests was per-
formed by two experienced ophthalmologists (one
with 10 years of experience and one with 40 years of
experience) who were blinded to the MRI findings.
After assessments were performed independently,
the analyses were compared jointly, and any differ-
ences in grading were adjudicated by consensus.
VF test findings were classified as normal (i.e.,
no defect), unreliable, or as one of the following
types of defect: bitemporal (bitemporal defect
only, including BHA), mixed (bitemporal and ad-
ditional defects), monocular, homonymous, non-
specific, or other. BHA, which was included as
one type of a bitemporal field defect, was diag-
AJR:205, November 2015 W513
nosed when the defect affected the entire outer (or
lateral) half of the VF in each eye.
A bitemporal defect was diagnosed when the
defect affected the outer (or lateral) half of the
VF in each eye, whereas a mixed defect was diag-
nosed when the defect involved not only the out-
er (or lateral) half of the VF of both eyes but also
other areas of the VF in one or both eyes. A mon-
ocular defect was defined as the presence of any
VF defect in one eye and a normal VF in the other
eye. A homonymous defect was defined as a de-
fect that was present in the temporal (outer) field
of one eye and the nasal (inner) field of the other
eye and, for the purpose of this study, was thought
to be consistent with a compressive lesion in the
region of the chiasm. Nonspecific defects were de-
fined as defects that could not clearly be attributed
to a particular ocular or neurologic process. The
other category identified defects that the evalu-
ators thought were not likely caused by the tumor.
Finally, unreliable test results were defined as re-
sults associated with excessive false-positive re-
sponses, false-negative responses, or fixation loss-
es still requiring interpretation.
Qualitative analysis of the degree of asym-
metry in VF loss between the right and left eyes
was also performed for patients with bitemporal,
mixed, or homonymous defects. The scale used
in such analysis included the following categories
of asymmetry: significantly more left, somewhat
more left, symmetric, somewhat more right, and
significantly more right.
The four patients who were found to have un-
reliable results of VF testing or who received a di-
agnosis consistent with other ocular or neurologic
diseases were excluded from further analysis.
Analysis of MR Images
Each patient underwent an MRI examination
that consisted of a standard protocol of sagittal and
coronal T1-weighted and CISS/FIESTA (construc-
tive interference in steady statefast imaging em-
ploying steady-state acquisition) sequences per-
formed before and after gadolinium contrast agent
administration. All sections were 3 mm or thinner.
We evaluated the degree of displacement of the
prechiasmal optic nerve, optic chiasm, and postchi-
asmal optic tract by the pituitary macroadenoma. If
there was symmetric displacement, we determined
the degree of displacement relative to the expected
normal location of the visual pathway. If there was
bilateral but asymmetric displacement, we com-
pared the displacement on each side with the ex-
pected location of the visual apparatus. Finally, if
there was unilateral displacement, we determined
the displacement of the affected side relative to the
position of the unaffected side. In all cases, the de-
gree of optic pathway displacement was classified
as no contact, abutment but not displacement, mild
displacement (<3 mm of displacement), or moder-
ate displacement ( 3 mm of displacement) (Fig.
1). We selected the maximum displacement when
more than two parts of the optic pathway were dis-
placed by the pituitary macroadenoma.
Two neuroradiologists (one with 8 years of ex-
perience and one with 3 years of experience) inde-
pendently measured displacement with the use of
electronic calipers. The mean of the two recorded
displacements was used, unless there was a discrep-
ancy of more than 3 mm, in which case an adjudica-
tion was performed by a third neuroradiologist (with
25 years of experience), who was blinded to the
measurements of the other two neuroradiologists.
Asymmetry from right to left in the degree of
compression of the optic pathway on MRI was
evaluated subjectively (Fig. 2). Adjudication was
performed in the same manner as it was for dis-
placement. We also recorded changes in signal in-
tensity on T2-weighted or FLAIR sequences, con-
trast enhancement, and atrophy anywhere along
the optic pathway and determined the presence of
hemorrhage in the pituitary lesions.
The imaging parameters used for the sagit-
tal thin T1-weighted sequence were as follows:
TR/TE, 450/9.5; matrix, 256 256; FOV, 150
150 mm; and section thickness, 2 mm. The coro-
nal thin T1-weighted sequence was obtained us-
ing the following parameters: TR/TE, 450/9.5;
matrix, 256 256; FOV, 150 150 mm; and sec-
tion thickness, 2 mm. The parameters used to ob-
tain the axial T2-weighted sequence were TR/TE,
4050/89; matrix, 384 384; FOV, 220 220 mm;
and section thickness, 4 mm. FLAIR sequence pa-
rameters were as follows: TR/TE, 9000/105; in-
version time, 2500 ms; matrix, 320 320; FOV,
230 230 mm; and section thickness, 4 mm.
The contrast-enhanced thin coronal T1-weighted
sequence was obtained using the following param-
eters: TR/TE, 500/9.5; matrix, 256 256; FOV,
150 150 mm; and section thickness, 2 mm. The
contrast-enhanced thin sagittal T1-weighted se-
quence was obtained with the use of the param-
eters TR/TE, 450/9.4; matrix, 256 256; FOV,
150 150 mm; and section thickness, 2 mm. The
parameters used to obtain the contrast-enhanced
axial T1-weighted sequence were TR/TE, 550/12;
matrix, 320 320; FOV, 220 220 mm; and sec-
tion thickness, 4 mm. The contrast-enhanced cor-
onal T1-weighted sequence was obtained using
the following parameters: TR/TE, 650/9.1; ma-
trix, 320 320; FOV, 230 230 mm; and section
thickness, 4 mm.
Results
Of the 115 patients (49 women and 66 men;
mean [SD] age, 54.7 6.2 years; age range,
 Lee et al.

1488 years), 70 had pathologically proven

pituitary macroadenoma, whereas 45 had pi-
tuitary macroadenoma diagnosed on the basis
of clinical findings, hormonal analysis, and
imaging findings. The height of the 115 le-
sions ranged from 0.4 to 5 cm (mean, 2.17
0.79 cm). Of the patients studied, 57 (49.6%)
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had moderate displacement (range, 321 mm)

of the optic apparatus by the pituitary mac-
roadenoma (Figs. 3 and 4), 27 (23.5%) had
mild displacement, and eight (7%) had abut-
A B ment but no displacement. In the remaining
23 patients (20%), the lesion had no contact
with any optic pathway structures.
Of the 92 patients with pituitary macroad-
enoma showing contact with parts of the op-
tic pathway, 79 (85.9%) had contact with two
or more areas. The areas of contact were the
prechiasmal optic nerve and optic chiasm
(58 patients); the prechiasmal optic nerve,
optic chiasm, and postchiasmal optic tract
(20 patients); and the optic chiasm and post-
chiasmal optic tract (one patient). In the re-
maining 13 patients, the lesion had contact
C D with only one area: the optic chiasm (nine
patients) or the prechiasmal optic nerve (four
Fig. 1MRI classification of degree of optic pathway displacement in patients with pituitary macroadenoma. patients) (Fig. 5).
A, MR image shows no contact between optic pathway and pituitary macroadenoma.
B, MR image shows pituitary macroadenoma abutting but not displacing optic pathway. Sixty-three patients had no document-
C, MR image shows less than 3 mm of displacement (i.e., mild displacement) of optic pathway caused by ed visual complaints. The other 52 patients
compression by pituitary macroadenoma. complained of visual disturbances, including
D, MR image shows displacement of 3 mm or more (i.e., moderate displacement) of optic pathway caused by
compression by pituitary macroadenoma. blurred vision (20 patients), diplopia (four
patients), or visual change (28 patients).

Asymptomatic Subjects
Sixty-three patients had no visual com-
plaints at presentation; in 14 of these pa-
tients (22.2%), the tumors had no contact
with the optic pathway. In the remainder
of the patients, tumor contact with the op-
tic pathway was as follows: four patients
(6.3%) had tumor abutment but no dis-
placement, 20 (31.7%) had mild displace-
ment, and 25 (39.7%) had moderate dis-
placement. The formal VF test findings for
these asymptomatic patients were classified
as follows: 18 patients (28.6%) had normal
findings, 14 (22.2%) had bitemporal defects
(without BHA), six (9.5%) had mixed de-
fects, one (1.6%) had homonymous defects,
eight (12.7%) had monocular defects, and 16
(25.4%) had nonspecific defects (Fig. 6).
A B
Symptomatic Subjects
Fig. 2MRI classification of asymmetry in the degree of compression in the optic pathway in patients with Fifty-two patients had visual complaints at
pituitary macroadenoma. presentation; in nine of these patients (17.3%),
A, MR image shows asymmetric displacement of right visual field of optic pathway caused by compression by
pituitary macroadenoma.
the tumor had no contact with the optic path-
B, MR image shows asymmetric displacement of optic pathway caused by compression by pituitary way. In the remainder of the patients, tumor
macroadenoma. contact with the optic pathway was as fol-

W514 AJR:205, November 2015

 Visual Defects Noted on MRI Examination of Patients With Pituitary Adenomas

lows: four patients (7.7%) had abutment but

no displacement, seven patients (13.6%) had
mild displacement, and 32 (61.5%) had mod-
erate displacement. For these symptomatic pa-
tients, VF test results were graded as follows:
eight patients (15.4%) had normal findings,
15 (28.8%) had bitemporal defects (with only
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one BHA noted among these 15 patients), 14

(26.9%) had mixed defects, four (7.7%) had
monocular defects, and 11 (2.1%) had nonspe-
cific defects (Fig. 7).

Visual Field Analysis

A B
Overall, 89 patients (77.4%) had abnormal
Fig. 3Patient with pituitary macroadenoma. VFs, and 26 patients (22.6%) had normal
A and B, Measurement of optic pathway displacement at level of prechiasmal optic nerve. Coronal unenhanced VFs. Of the 89 patients with abnormal VFs,
(A) and contrast-enhanced (B) T1-weighted MR images show 6 mm of displacement of prechiasmal optic nerve. bitemporal or mixed defects were present in
Normal position of optic pathway (bar, A) and distance from normal position (arrow, A) are shown.
49 patients (representing 55.1% of this group
and 42.6% of all 115 subjects) and were the
most common patterns, followed by nonspe-
cific defects (27 patients), monocular defects
(12 patients), and homonymous defects (one
patient) (Fig. 8).
Of the 49 patients with bitemporal or mixed
defects, 42 (85.7%) had moderate displace-
ment (range, 421 mm), five (10.2%) had mild
displacement, and two (4.1%) had lesions with
no contact with the optic pathway. Of the 49
patients with bitemporal field deficits, only
one patient had BHA. This patient had moder-
ate displacement of the optic pathway.
A B When moderate displacement (optic path-
way displacement greater than 3 mm) was
Fig. 4Patient with pituitary macroadenoma. used as the criterion for identifying bitem-
A and B, Measurement of optic pathway displacement at level of optic chiasm. Coronal unenhanced (A) and
contrast-enhanced (B) T1-weighted MR images show 9 mm of displacement of optic chiasm. Normal position of poral or mixed defects, VF testing had a sen-
optic pathway (bar, A) and distance from normal position (arrow, A) are shown. sitivity of 85.7% (42/49), specificity of 75%
(30/40), a positive predictive value of 80.8%
70
(42/52), a negative predictive value of 81.1%
(30/37), and accuracy of 80.9% (72/89).
60 When the 27 patients with nonspecific
Pituitary Macroadenomas (no.)

VF defects were excluded, 42 of 49 patients

50 (85.7%) with bitemporal or mixed defects had
moderate optic pathway displacement result-
40
ing from masses, whereas two of 13 patients
30
(15.4%) with atypical, homonymous, or mon-
ocular defects had moderate displacement.
20
Asymmetry
10 For 41 of 115 patients, asymmetry in the
degree of compression of the optic pathway
0
Prechiasmal Prechiasmal Prechiasmal Optic Nerve and Optic noted on MR images was from right (15 pa-
Optic Nerve Optic Nerve and Optic Nerve, Postchiasmal Chiasm tients) to left (26 patients).
Optic Chiasm Optic Chiasm, Optic Tract
and Postchiasmal Asymmetry in the degree of VF damage
Optic Tract between right and left eyes was also noted
Area(s) of Contact With Optic Pathway in 39 of 49 patients (79.6%) with bitemporal
or mixed defects, and symmetry was noted
Fig. 5Graph showing relationship between optic pathway and pituitary macroadenoma in 92 patients with in 10 of 49 patients (20.4%). For predicting
pituitary macroadenoma that had contact with optic pathway. asymmetry of the right and left VFs, MRI

AJR:205, November 2015 W515

 Lee et al.

had a sensitivity of 43.6% (17 of 39 patients),

specificity of 80% (8 of 10 patients), a posi-
30
tive predictive value of 89.5% (17 of 19 pa-
tients), a negative predictive value of 26.7%
25
(8 of 30 patients), and accuracy of 51% (25 of
49 patients) (Fig. 9).
One of the 115 patients (0.9%) had atro- 20
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Patients (no.)
phy of the optic chiasm, and 19 (16.5%) had Normal
hemorrhage. With the exception of one pa- 15 Nonspecific defects

tient (0.9%) who had high signal intensi- Monocular defects

Homonymous defects
ty noted in the left postchiasmal optic tract 10 Bitemporal or misdefects
on T2-weighted or FLAIR images, we did
not find any signal change on T2-weighted
5
or FLAIR images. There was no optic path-
way component enhancement. The pa-
tient who had high signal intensity noted on 0
Moderate Mild Abutting No Contact
T2-weighted or FLAIR images had a mixed Displacement Displacement
VF defect. Tumor Contact With Optic Pathway

Discussion
Fig. 6Graph showing relationship between displacement of optic pathway and visual fields in 63 patients
Our study confirms that the classic find- without visual complaints.
ing of pure BHA in patients with pituitary
macroadenoma is a myth; only one of the
115 patients in our cohort had this defect. In
fact, the VF defects in our patients with pi- 35
tuitary macroadenoma were purely bitempo-
ral (even if incomplete) in only 29 of 115 pa- 30

tients (25.2%); we found mixed defects with

25
areas of VF loss outside the temporal fields
in 20 of 115 patients (17.4%). These find-
Patients (no.)

ings are comparable to those of other neu-
roophthalmologic studies, which found that
pure BHAs are rare compared with bitempo-
ral defects, with the former occurring in only
approximately 1% of patients with pituitary
macroadenoma [1, 8, 9].
We also found that patients with macroad-
enoma may have other defects, including
monocular or homonymous defects [5, 10
12]. Indeed, 40 of the 89 patients with VF de-
fects (44.9%) had nontemporal defects. This
may have resulted from compression of pre-
chiasmal optic nerves or postchiasmal tracts.
Involvement of prechiasmal optic nerves or
postchiasmal tracts was seen in 82 and 21 pa-
tients, respectively. Of the patients with pre-
and postchiasmal compression, 79 also had
optic chiasm compression. Only nine patients
had pure optic chiasm compression alone.
Thus, it is more common to have extrachias-
mal optic pathway involvement along with
compression of the chiasm, rather than just
chiasm compression alone. Previous studies
did not evaluate extrachiasmal compression,
evaluating only chiasmal compression instead.
In general, VF defects (whether bitempo-
ral, mixed, homonymous, or monocular) cor-
related with the degree of optic pathway dis-
20
15
10
5
0
Moderate Mild
Displacement Displacement
Tumor Contact With Optic Pathway
Fig. 7Graph showing relationship between displacement of optic pathway and visual fields in 52 patients
with visual complaints.
placement noted, with 71% of patients with
VF defects having moderate optic pathway
displacement that ranged from 4 to 21 mm.
Eight patients in this study had abnormal
VFs, a finding that was thought to be con-
sistent with optic pathway damage resulting
from their tumors, although MRI examina-
tion of these patients revealed no contact be-
tween the tumor and the optic apparatus. It
is possible that in some of these patients, the
VF defect was spurious or related to a proc-
ess other than the tumor. Alternatively, some
studies have theorized that the discovery of
Normal
Nonspecific defects
Monocular defects
Homonymous defects
Bitemporal or misdefects
Abutting No Contact
abnormal VFs in patients who have pituitary
tumors that do not appear to be in contact
with the optic apparatus may be attributed
to previous indentation (and subsequent tu-
mor regression), hormonal influences, intra-
tumor hemorrhage, autonecrosis, or vascu-
lar shunting [13]. In our study, the smallest
displacement of the optic apparatus from its
expected normal position in a patient with
a presumed related VF defect was 4 mm on
the coronal plane, compared with previous
reports indicating a minimum displacement
of 1213 mm [7, 9]. This discrepancy may

W516 AJR:205, November 2015

 Visual Defects Noted on MRI Examination of Patients With Pituitary Adenomas

In our study, asymmetry was noted on the

60
MR images of 41 of 115 patients (35.7%),
with MRI therefore having 43.6% sensitiv-
ity and 80% specificity for predicting asym-
50
metry on the VF test. This sensitivity and
specificity may be attributed to multiple fac-
40 tors, including the patients health status and
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Patients (no.)

Normal hormonal status, the follow-up period, and

30 Nonspecific defects the location and shape of tumor. However,
Monocular defects
Homonymous defects
the high positive predictive value (89.5%)
20 Bitemporal or misdefects of MRI in predicting asymmetry of the right
and left VFs suggests that when MRI shows
asymmetry to one side, there very frequently
10
is asymmetry in VF damage.
There are several limitations of this study.
0 First, not all of the patients had pathological-
Moderate Mild Abutting No Contact
Displacement Displacement ly proven tumors; thus, it is possible (although
Tumor Contact With Optic Pathway unlikely) that some of the lesions were not
adenomas. Second, there was a wide interval
(mean, 48.2 42.8 days; range, 0175 days)
Fig. 8Graph showing relationship between displacement of optic pathway and visual fields in all 115 study patients.
between MRI examination and VF testing, al-
though there was no documented statistical-
ly significant change in the size of pituitary
macroadenoma noted on serial MR images.
14 Third, there were three patients without a con-
12 trast-enhanced study and two patients without
T2-weighted or FLAIR images. Finally, there
10 likely is selection bias for patients with visual
Patients (no.)

symptoms to be referred for VF analysis.

8
Right asymmetry on MRI
6 Symmetry on MRI Conclusion
Left asymmetry on MRI Complete BHA associated with pituitary
4
macroadenoma is rare, occurring in only one
2 of 115 patients in our cohort. On the other
hand, bilateral temporal VF defects, either
0 pure or associated with additional defects,
Right Asymmetry Symmetry Left Asymmetry
are the most common defects noted in pa-
Results of Visual Field Testing tients with pituitary macroadenoma, occur-
ring in 42.6% of all patients. Most patients
Fig. 9Graph showing relationship of asymmetry between MRI and qualitative analysis of visual field test. had compression of the prechiasmal optic
nerves, the postchiasmal tracts, or both, in
addition to compression of the chiasm, which
be attributed to differences in the measure- In this study, a change in the signal in- may account for these impure VF findings
ment methods used in our study and previous tensity noted in the optic apparatus on that include areas outside the bitemporal
studies. The studies by Ikeda and Yoshimoto T2-weighted or FLAIR images was exceed- zones. Such defects are typically present in
[7] and Schmalisch et al. [9] measured the ingly rare, occurring in only one of 115 pa- patients with greater than 3 mm of displace-
degree of displacement of the optic chiasm tients. This finding is counter to the results ment of the optic apparatus. In addition, pa-
from the upper surface of the internal carot- reported in a previous study [14]. tients with asymmetric compression of the
id artery within the cavernous sinus, whereas Asymmetry in VF abnormalities was also optic pathway seen on MR images are likely
our study measured the degree of displace- noted and was confirmed by qualitative anal- to have asymmetric VF defects.
ment from the expected normal (presumed) ysis of the VFs (in 39 of 49 patients [79.6%])
location, according to the course of the op- and by MRI (in 41 of 115 patients [35.7%]). References
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that optic pathway displacement by pituitary asymmetry may also be attributed to a differ- syndrome. Graefes Arch Clin Exp Ophthalmol
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3. Jacobs DA, Galetta SL. Neuro-ophthalmology for
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