Quality of care evaluation in non-functioning pituitary adenoma with chiasm compression: visual outcomes and timing of intervention clinical recommendations based on a systematic literature review and cohort study

Abstract

Purpose: Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown.

Methods: Systematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed.

Results: Systematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay. Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5 ± 14.8 years), had a median MD of - 5.3 decibel (IQR - 3.1 to - 10.1). MD was strongly correlated with clinical severity (r = - 0.94, P < 0.0001), and were used for severity of defects cut-off values: (1) normal > - 2 dB, (2) mild - 2 dB to - 4 dB, (3) moderate - 4 to - 8 dB, (4) severe - 8 to - 17 dB, (5) very severe < - 17 dB.

Conclusion: Surgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.

Keywords: Non-functioning pituitary adenoma; Optic chiasm compression; Pituitary tumor; Transsphenoidal surgery; Visual fields; Visual outcome.

Fig. 1

Recommendation for timing of surgery depending on visual function and compression of optic chiasm and evaluation of NFMA patient cohort. a Timeframes for surgical intervention are divided into three categories: preferred (P), standard (S) and undesirable (U). In case of progression of clinical symptoms, upgrade to other patient group and advance surgical intervention. During surgical delay, VF and VA testing should be repeated according to ophthalmological FU timeframes: Group 1, every 3 months; Group 2, every 4 to 6 weeks; Group 3, every 1 to 3 weeks; Group 4, every 3 to 5 days. b Data are shown as number of patients (N) operated within the preferred, standard and undesirable timeframes as suggested in section a. Treatment delay (in days) is reported per patients in Italics. Performance indicators (PIs) were calculated for preferred (P-PI), standard (S-PI), and undesirable (U-PI) timeframes. FU follow-up, VF visual fields, VFD visual field defects, VA visual acuity, d day(s), w week(s), m month(s), D days, NFMA non-functioning adenoma, VFD visual field defects

Fig. 2

Flowchart of proposed referral delays depending on visual function and compression of optic chiasm. Proposed time(frames) for the referral of NFMA patients with visual acuity impairment or visual field defects from a non-expertise to an expertise center. VA visual acuity, VF visual field