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British Journal of Neurosurgery

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Recovery of vision following

transsphenoidal surgery for pituitary
adenomas
a

MICHAEL POWELL
a

The National Hospital for Neurology and Neurosurgery, Queen

Square, London, UK
Published online: 06 Jul 2009.

To cite this article: MICHAEL POWELL (1995) Recovery of vision following transsphenoidal surgery for
pituitary adenomas, British Journal of Neurosurgery, 9:3, 367-374
To link to this article: http://dx.doi.org/10.1080/02688699550041377

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British Journal of N eurosurg ery (1995) 9, 367 373

R EVIEW A RTIC LE

R ecovery of vision following transsphenoidal surgery for

pituitary adenom as
M IC HAEL PO W ELL

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The N ational Hospital for N eurology and N eurosurgery, Queen Square, London , U K

Abstract
The degree of recovery of vision is reported in 67 patients who underwent transsphenoidal surgery for pituitary
adenomas compressing the visual pathways. There were no deaths, but 14 patients experienced postoperative
complications. Overall, 88% showed visual improvem ent, 7% w ere unchanged and 4% were worse after surgery.
Key words: Pituitary adenomas, transsphenoidal surgery.

In a land m ark paper of the seventies, Professor Sym on set standards for transcranial
surgery for pituitary adenom as, and in particular for post-operative visual recovery, that have
never been equalled.1 The series of 101 patients was selected from a larger group, and
excluded recurrent and giant tum ours over 4
cm in size, although the m anagem ent of th e
giant tum ours was reported later.
That paper concentrated on three m ain issues. The rst section dealt with presentation,
particularly the visual details. O nly sketchy
endocrinological inform ation was given, and it
is clear that this was not at that tim e of m ajor
concern. The second section described th e
operative wo rk-up with the then available
technology of pneum oencephalography, angiograph y and the new C T scan (EM I 1010
and 5005 in axial cuts only), as well as th e
operative technique with the postoperative
m anagem ent in wh ich radiotherapy played a

m ajor part. Th e nal section concerned the

results, with impressively low m ortality of
0.99% (a single death from a postoperative
pulmonary em bolus), low m orbidity and excellent recovery of vision which had been
equalled, but not im proved by transsphenoidal
surgery. The other transcranial surgery series
m entioned in their paper all had a recorded
m ortality of over 5%, quite apart from any
visual or endocrine recovery, so the Sym on
series results were, by com parison, outstandingly good. However, nearly all patients required full horm one replacem ent and a
signi cant num ber left hospital with diabetes
insipidus, although som e of these recovered in
tim e.
The aim of the series of 67 patients reported
in this paper was to assess visual recovery
following transsphenoidal surgery, to identify
any indices that would point to successful visual recovery and nally to predict the rate at
which norm al pituitary function is preserved
following surgery.

0268-869 7/95/030367 07

1995, The Neurosurgical Foundation

Introduction

368

M . Powell
T ABLE I. Patient data

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M ales
Females
Age:
range
M ean
. 70 years

38
29
27 84
55
16 (23.9 %)

Com parison of this series with that reported

in the Sym on paper illustrates the evolution of
ideas that has taken place in the last 15 years,
em phasizing th e differences in m anagem ent
and, in particular, the surgical approach m ost
pituitary surgeons have adopted in the 1990s
since the pioneering work of transsphenoidal
exp erts such as Hardy.2 It is readily accepted
that there has been little change in the outcom e as regards vision, recovery of which depends on th e severity of loss and possibly
length of history and, to a lesser extent, age at
presentation. The im provem ents offered by
the transsphenoidal approach are in the low
stress and m orbidity, and the m uch better
results in term s of preservation of endocrine
function, in particular lack of diabetes insipidus.

Patient selection
Sixty-seven patients with pituitary adenom as
are presented. Visual disturbance was the only
criterion for inclusion in the group. Their
m ean age was 55 years (range 27 84 years).
There were 38 m ales and 25 fem ales (Table
I). In addition, other sym ptom s were displayed, including 15 with headache (21.7% )
and tw o patients with m assive tum ours causing sym ptom s of raised intracranial pressure.
A further 18 (11.9% ) patients also had proven
hypopituitarism , presenting with weight loss,
lack of energy and general apathy . A further
four patients had individual horm one dysfunction, tw o were acrom egalics, one had postadrenalectom y (N elson) syndrom e and one
patient presenting with am enorrhoea, as

sh ow n in Table II. All tw elve prem enopausal

wom en (17.9% ) had lost their m enstrual
cycle, although only one had com plained of it.
A ll tum ours had extended into the suprasellar space. In this series m assive tum ours were
not discounted, ve (7.4%) patients having
m ultilobed tum ours de ned by the Hardy
classi cation 2 as D and E, which wo uld have
been speci cally excluded in the Sym on series.
Two patients (2.9% ) had had previous transcranial surgery and radiotherapy, and one
transcranial surgery alone.
A ll patients underwent transsphenoidal
surgery, though 12 subsequently underwent
a second procedure either by the transcranial
(seven) or a second transsphenoidal approach.

Visual data
All patients were independently assessed by
the Departm ent of N euro-O phthalm ology at
this institution. Visual elds were recorded by
the G oldm an Field m ethod (the I4e perim eter
was used in this assessm ent), as well as length
of history, acuity and the presence of optic
atrophy. Preoperative visual data are recorded
in Table IIIb. The relatively com plex visual
scoring system s suggested by Findlay et al. 3
and by Cohen et al. 4 were not em ployed, but a
very sim ple system was used, based on sim ple
scoring of eld quadrants and acuity (Table
IIIa). O ptic atrophy in one or both eyes was
present in 44 (65.7%) of patients.

T ABLE II. Symptom s at presentation (% )

Symptom
Visual problems
Headache
Pan hypopituitarism
Acromegaly
Nelsons
Prolactinom a
Am enorrhoea

%
100
21.7
11.9
3
1.5
1.5
17.9

Recovery of vision
Im aging

T ABLE III.
(a) Field recording system
05
15
25
35
45
55

Normal elds
Quadrantinopia
H emi eld
Less than hem i eld
H and movement or nger counting
No perception of light

(b) Ophthalm ic history (duration:1 300 m onths)

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Defect
Field
Acuity
Atrophy

369

None

m onocular

binocular

6
19
24

16
24
10

45
14
33

E nd ocrine data
A ll patients underwent preoperative assessm ent of endocrine function which included
fasting cortisol level, thyroid function, prolactin and gonadotrophin levels. Not all patients with below norm al cortisol levels had
sym ptom s of hyp ocortisolaem ia. Th e patient
operated on for a prolactinom a had undergone
a trial of brom ocriptine and was brom ocriptine insensitive with no change in tum our size on m edical therapy, unlike th e
m ajority of prolactinom as which respond with
dram atic sh rinkage of the tum our and thus do
not require surgery. Two patients had
acrom egaly and one postadrenalectom y Nelson s syndrom e, although m any `silent tum ours displayed horm one containing granules
on imm unocytochem istry assessm ent (Table
VIII).

T ABLE IV. Postoperative com plications

Postoperative com plication
CSF leak at surgery
T ransient diabetes insipidus
H aematoma
Cardiorespiratory event? Pulm onary embolus
Confusion

No.
5
4
3
1
1

All patients were assessed with either transm ission CT or later in the series if possible
with M R I, with and without gadolinium enhancement. Early on in the series a few patients had angiography as well as C T, though
this was th en abandoned by the author as
non-contributory. W hen perform ed, the presence or absence of a tum our `blush on angiography did not correlate with operative tum our
vascularity. The risk of an intra- or suprasellar
aneurysm is very sm all and at no tim e did
angiography alter m anagem ent, except in one
76-year-old m an who developed a m ild stroke
following angiography and who refused
surgery for a further 3 years as a result, although fortunately with a signi cant im provem ent in his vision once it had been perform ed.
W ith the improved quality of CT and particularly with M RI the need for angiography is in
any case avoided.
Neither pneum oencephalography nor routine plain radiography of the skull have been
part of the preoperative investigation of any
patient of this series.

Surgery
Although all patients underwent transsphenoidal surgery perform ed by the author, the
style of the operation changed in 1987 from
the traditional H ardy technique as is taught
alm ost universally in the U K, to an am algam
of techniques borrowed from the `endonasal
approach described by Landholdt using the
position as advocated by Fahlbusch. 5
A t induction of anaesthesia, all patients
were given 100 m g of intravenous hydrocortisone and 750 m g of cefuroxim e. In this group
of patients with suprasellar extension of their
adenom a, a lum bar drain was inserted to facilitate tum our rem oval. Im age intensi cation
and the operating m icroscope were used.
The cartilaginous septum is not resected,
m erely de ected in this approach, the bony
septum to the vom er rem oved and the sp henoid air sinus opened, using th e Landholdt
m odi cation of the H ardy C ushing retractor.

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370

M . Powell

The pituitary fossa is identi ed paying particular attention from the im aging to the sinus
septation, which can be m isleadingly asym m etrical, risking m isidenti cation of the m idline. If the oor is intact, it is opened using th e
diam ond drill on the long cranked hand piece,
although this is often unnecessary in th e large
tum ours as the oor is so thinned by th e
pressure from the tum our.
W ith th e oor rem oved the fossa is em ptied
of tum our rst and the dom e of the tum our
brought down by introducing 5-m l aliquots of
saline into the lum bar drain. The m axim um
quantity used to date has been 70 m l, but
15 25 m l is m ore com m on and spinal C SF
pressure is now m onitored during the saline
injection. The m ain problem is prolapse of th e
anterior part of the tum our dom e before th e
posterior, which then obscures vision. This
can be pushed up, using a sm all or m edium
patty . The dom e of the tum our is a th in layer
of attenuated m eninges pulsating with respiration and heartbeat. Pockets of tum our are
often hidden behind sm all prolapses of this
layer so careful searching is necessary.
CSF leaks are rare, but if they occur th e
fossa can be patched with two layers of fascia
lata harvested from the thigh. H aem ostasis is
not usually a problem , once the m ajority of th e
tum our is rem oved. If it is, th en a com bination
of tim e, gelfoam and gentle packing usually
suf ces. O ccasionally dural bleeding points require bipolar coagulation. The fossa is not
closed unless there is a CSF leak. G elfoam
alone is placed in the defect. N o problem s
have been m et using this m ethod, in particular
no cases of m eningitis. Although tw o patients
had m eningitic sym ptom s brie y, no organism
was found. U nless the patient has a leak they
are m obilised the next day. If a leak is present
they are nursed in bed for three days slightly
head up with the lum bar drain in place, draining at bed height, approximately 90 m l a day.
There have been no incidents of long term
C SF leaks using this m ethod.

Postoperative m anagem ent

The patient receives tw o m ore doses of th e

prophylactic antibiotic and a tapering dose of

hydrocortisone from 100 m g b.d. to a m aintenance dose of 20 m g in the m orning and 10
m g in the afternoon. The patient can usually
be discharged at 5 7 days after operation,
som etim es sooner on this dose of hydrocortisone, for long-term endocrine follow-up. Visual elds are checked before discharge.
Follow-up is carried out in a m ultidisciplinary clinic with neurosurgeon, endocrinologist, radiotherapist and ophthalm ic services.
The m ajority of patients (69.2% ) are referred
to radiotherapy once adequate clearance of
the tum our is established by postoperative
im aging. Elderly patients are not referred,
nor younger patients if the fossa is com pletely emptied, as pituitary failure in 12 15
years later is the inevitable consequence of
radiation, as well as the risk of second tum our
induction.6 The need for second surgery
has diminished with exp erience and is now
infrequent. H ow ever, 12 patients went on
to a second procedure, although th eir vision
often improved despite an inadequate
clearance.

Results
There were no operative deaths, and the m orbidity was very low as shown in Table IV. The
m ain problem s were ve tem porary CSF
leaks, m anaged as outlined above with no
long-term established stulae and four patients with transient diabetes insipidus. Postoperative scanning revealed a haem atom a in
the pituitary fossa in three patients, one requiring urgent evacuation, although her vision
ultim ately improved.
O verall vision (acuity and elds) improved
in the m ajority of patients, the details are
sh ow n in Tab le V recorded at 6 m onths from
surgery. If elds are considered separately,
nearly all the patients had som e loss (61 of
67). O f these, 77% improved, notably 34% to
norm al (de ned as anything less than quadrantic eld loss), although in one case (1.5%)
a single eld was wo rse. A cuity reduction was

Recovery of vision

371

T ABLE V. Visual recovery

Outcome

M onocular

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Overall
Improved

14

Unchanged
W orse
Visual acuity
Improved

2
1

Unchanged
W orse
Visual elds
Improved

13
3

11

Unchanged
W orse
Recovery to normal
Acuity
Fields

far less frequent (38 of 67). O f th ese, 45%

improved, but only 13.4% to norm al (6 out of
9 or better). Acuity changes did not parallel
change in visual elds in every case, so that
although elds could improve, acuity could be
fractionally worse, resulting in an overall net
improvem ent.
If the patients with a history of 1 year or less
are considered separately, the visual improvem ent, despite previous expectations, was only
82.6% im proving, better than the total but
only 22.7% to norm al, wo rse than the total, as
shown in Table VI. In view of the sm all num bers, th is difference is of doubtful statistical
signi cance.
Patients with optic atrophy at presentation
m ight be considered as having longer histories

T ABLE VI. Visual elds in patients with history of less

than 1 year (n 5 23)
Outcome

Monocular

Binocular

Improved

11(82.6% )
Cure 5 (21.7 %)
3
1

U nchanged
W orse

Binocular

45
(31 both 14 one) 5
3
2
9
(5 both 4 one) 5
4
1

4
1

36
(27 both 9 one) 5
9
0

6
9

3
14

88%

45%

77%

(13.4% )
(34.3% )

and therefore their visual recovery expected to

be less com plete. However, even in this group,
the vision improved to som e extent as is shown
in Table VII. Long-term follow-up has shown
that vision can continue to improve for as long
as the patient is followed up, with m inor improvem ent still occurring at 3 years following
surgery and radiotherapy.
Endocrine results are shown in Table IX .
Apart from the very low and in all but one case
transient episodes of diabetes insipidus, the
endocrine function of these patients following
surgery is gratifyingly preserved. Eight patients
entered with an established panhyp opituitary
state and there was no recovery of pituitary
function in these patients. H ow ever, if the
patient entered with som e function, the m ajority of function was retained.

T ABLE VII. Recovery in patients

with optic atrophy
Normal elds
Improvement

23.1%
50.0%

Normal acuity
Improvement

22.7%
54.5%

372

M . Powell
T ABLE VIII. Immunocytochemistry
Prolactin
LH
FSH
GH
AC TH
T SH

7
12
10
4
6
7

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D iscussion
The results presented in th is paper show no
absolute advantag e in visual recovery following transsphenoidal surgery com pared with
the transcranial route, with the overall improvem ent alm ost identical (88 94%). R etrospective com parisons are always fraugh t with
dif culty, as no tw o series are directly com parable. There were a num ber of exclusions in th e
Sym on series which m ight have had a further
improving effect on results if they had been
em ployed in this series, although it would have
m ade the num bers rather sm aller; furtherm ore, the results of the Sym on series are so
rem arkably go od as to be dif cult to improve
on.
There have been three previously reported
series th at consider visual recovery after
transsphenoidal surgery, all quoting very sim ilar gures to those reported here. 3,4,7 All have
very low m orbidity and no m ortality. U nder
the circum stances, there can be little
justi cation in offering patients with large
suprasellar pituitary tum ours and visual sym ptom s a transcranial decom pression as a rst
procedure, unless there are unusual circum stances, such as a sm all fossa or a nonpneum atized sphenoid. That the Sym on
transcranial operation had so few problem s
was, surely, unusual and m ust be attributed
entirely to Professor Sym on s skill. Even today, with im provem ents in anaesthesia and

equipm ent, the transcranial procedure has a

higher perceived risk than the transsphenoidal.
Furtherm ore, there are risks of epilepsy, the
driving licence is suspended for a year and
endocrine function is seldom preserved.
A short length of history has been noted by
som e authors as being the m ost signi cant
feature that determ ines good recovery of vision. This paper does not con rm that this is
necessarily the case. Although not reported
here, vision can recover for m any m onths beyond the 6-m onth period used in this report.
This series, as analysed here, does not identify
any particular factors that would be predictive
of a favourable outcom e. However, ongo ing
work, not reported, would seem to indicate
that the m ost important factor in visual recovery is the extent of the visual de cit at presentation. Nevertheless, patients in whom acuity
or elds are substantially reduced can m ake
useful recovery.
Endocrine m anagem ent of these patients is
also a m ajor part of the follow-up. These patients undergo a barrage of postoperative testing, som e of which are unpleasant and, in the
case of those patients of endocrinologists who
still em ploy the insulin tolerance test to assess
cortisol response, not without risk. If norm al
endocrine function can be preserved, the follow-up m anagem ent is easier and well-being
of the patient in nitely better. The current
debate am ongst endocrinologists relates to the
need for growth horm one replacement. Its
lack in the panhypopituitary state m ay prejudice longevity, stress tolerance and general
well-being, despite replacem ent of cortisol,
thyroxine and sex horm ones. If this debate
con rm s the need for growth horm one replacem ent, preservation of pituitary function
will have a signi cant part in containing total
m anagem ent costs, unless the price of growth
horm one replacement falls.

T AB LE IX. Endocrine status after surgery

Preserved function
Corrected excluding those patients with preoperative panhypopituitarism
Permanent diabetes insipidus

41 (61.2% )
83.7%
1 (1.5% )

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Recovery of vision
The som ewhat disappointing feature of this
series is the reoperation rate. Although 12
patients went on to a second procedure, tw o
were as a planned two-stage procedure because of a bilobed tum our in which the lobes
were separated by a pre xed optic chiasm .
The frequency of the need for a second procedure is now m uch less in this author s series,
re ecting the steady technical improvem ent
learnt by experience. It is of interest that
H ardy reported his ow n, newly adopted, m ultioperation transsphenoidal approach for giant
tum ours, each procedure separated by 6-w eek
intervals, at the pituitary session of the International Skull Base Surgery M eeting in
H anover in 1992.
In conclusion, transsphenoidal surgery is a
safe and effective m ethod for restoring
signi cant function to vision dam aged by large
pituitary adenom as whilst preserving endocrine function.

M edical School, London, all of whom would,

under norm al circum stances, be co-authors.

Address for correspondence: M r M . Pow ell, The

National
H ospital
for
N eurology
and
Neurosurgery, Q ueen Square, London W C 1N
3BG, UK

References
1

A cknowledgem ents
I would like to acknow ledge the signi cant
contribution of Dom inic Thom pson and
C herie Levi, of the National Hospital, and
Paul K elland of The M iddlesex Hosp ital

373

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Findlay G, M cFazdean RM , Teasdale G . Recovery
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managem ent of acrom egaly. Endocrine M etabolic
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Laws ER Jr, Trautm ann JC, Hollenhorst RW .
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