|Year : 2019 | Volume
| Issue : 3 | Page : 119-124
Ocular manifestations in patients with intracranial space-occupying lesions
Vrushali Shende1, Sandeep Iratwar2, Sachin Daigavane1
1 Department of Ophthalmology, JNMC, Wardha, Maharashtra, India
2 Department of Neurosurgery, JNMC, Wardha, Maharashtra, India
|Date of Submission||10-Jun-2019|
|Date of Decision||22-Jul-2019|
|Date of Acceptance||10-Aug-2019|
|Date of Web Publication||2-May-2020|
Dr. Vrushali Shende
Plot No. B22/1, Besides Gandhigram College, MIDC, Wardha - 442 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: This study aims to study the ocular manifestations in patients with intracranial space-occupying lesions (ICSOLs). Materials and Methods: Cross-sectional hospital-based study. Minimum of 70 patients diagnosed and undiagnosed with ICSOL coming to ophthalmology OPD, neurosurgery OPD, and admitted patients to any ward of Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, were selected. Selected patients underwent detailed clinical history, neurological and ocular examination depending on presenting ocular complaints. Results: The study included 36 males and 34 females. 68.57% of ICSOLs were found in the supratentorial compartment of the brain. The most common ocular symptom was diminution of vision followed by doubling of vision, loss of vision, drooping of eyelids, and protrusion of the eyeball. Commonly seen ocular sign was papilledema followed by visual field defect. Glioma (18.57%) and meningioma (18.57%) were encountered to be the most common ICSOLs followed by vestibular schwannoma (17.14%). Other ICSOLs were pituitary adenoma (11.43%), chronic subdural hemorrhage (8.57%), craniopharyngioma, epidermoid cyst, etc. It was observed that symptoms and signs correlated with the location of ICSOL. Conclusion: Ophthalmologists play important role in intracranial localization of ICSOLs depending on ocular symptoms and signs; thus, early diagnosis and referral to neurosurgeon promote early treatment.
Keywords: Diminution of vision, intracranial space-occupying lesions, papilledema, visual field defect
|How to cite this article:|
Shende V, Iratwar S, Daigavane S. Ocular manifestations in patients with intracranial space-occupying lesions. J Datta Meghe Inst Med Sci Univ 2019;14:119-24
|How to cite this URL:|
Shende V, Iratwar S, Daigavane S. Ocular manifestations in patients with intracranial space-occupying lesions. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 4];14:119-24. Available from: http://www.journaldmims.com/text.asp?2019/14/3/119/283579
| Introduction|| |
The eye is said to be the MIRROR of the brain. Any change inside skull is reflected through ocular signs and symptoms. Morphologically and functionally, the visual system, as a whole can be called as little brain. Knowledge of visual system anatomy along with skillful examination helps in localizing the neuropathological processes. Most importantly, this knowledge helps in accurate diagnosis, appropriate intervention and better prognosis. An “Intra-cranial space-occupying lesion” (ICSOL) is defined as a mass lesion in the cranial cavity. The etiology of ICSOLs is benign neoplasm, malignant neoplasm, inflammatory lesion, parasitic lesion, hematoma, and arteriovenous (AV) malformation. The incidence of central nervous system tumors in India ranges from 5 to 10 per 100,000 population with an increasing trend and accounts for 2% malignancy. Hence, early diagnosis and prompt treatment of ICSOLs is necessary.
Different ocular manifestations depend on the site of ICSOL, thus presents as effect on visual pathway, ocular nerves, and orbito-ocular tissues. Systemic symptoms include headache, projectile vomiting, seizures, referred pain to face or ear and throat. Systemic signs comprise of altered sensorium, hypertonicity in limbs, changes in vitals such as bradycardia, irregular respiration, and hypertension. Ocular symptoms of raised Interactive Cognative Task (ICT) are deviation of eye diplopia and diminution of vision (DOV) depending on the area of the brain involved. Ocular signs include papilledema, cranial nerve palsies, nystagmus, scotomas, and optic atrophy.
Presentation of ocular signs and symptoms in brain tumors depends on type, site, and size of lesion in patients with ICSOL. Ocular features may be seen much earlier than systemic signs. Hence, in cases of ICSOL, ophthalmologists play a vital role in early diagnosis and referral to neurosurgeon. In developing countries like India, where expensive investigations such as computed tomography/magnetic resonance imaging (CT/MRI) are financial burden, careful neuro-ophthalmic evaluation helps diagnosing neurological disorder with fair amount of accuracy. Most of the intracranial tumors first produce ocular signs and symptoms and hence are first detected by an ophthalmologist. Thus, we conducted this study with the aim to evaluate ocular manifestations in patients with ICSOLs.
| Materials and Methods|| |
A cross-sectional study was conducted from September 2017 to August 2019 for 2 years at rural hospital on 70 diagnosed or undiagnosed cases of ICSOL visiting ophthalmology OPD, neurosurgery OPD, or admitted to any ward of the hospital. The study is adherent to the declaration of Helsinki. Patients with signs and symptoms of raised intracranial pressures, with vascular lesions, intracranial space-occupying inflammatory lesions or aneurysms were included. Whereas, patients who were uncooperative on account of deteriorating general conditions and marked behavioral changes, history of previous head injury, demyelinating diseases, or communicating hydrocephalus were excluded. Detailed clinical history was taken of all patients then underwent neurological and ophthalmic examination depending on presenting ocular complaints. Distant and near vision, color vision, torchlight examination, slit-lamp biomicroscopy, tonometry by non-contact tonometry (NCT), fundus examination, extraocular movements were examined. The visual field was tested by automated perimetry in all cooperative individuals. Symptoms such as transient blurring of vision, progressive DOV, headache, projectile vomiting, diplopia, deviation of eyes, protrusion of eye, and drooping of eyelids were further investigated. General and central nervous examinations were performed to find out signs of raised intracranial tension and any systemic neurological deficit. The complete external examination of eye was done. Any abnormality in head posture that might have been assumed to overcome diplopia was noted. The palpebral apertures were compared and any widening because of lid retraction or proptosis was noted. Any lagophthalmos because of facial nerve palsy was noted. If proptosis was present, it was completely examined, its directions were noted and measurements were taken. Similarly, where ptosis was present, its examination was done in detail. Corneal sensations in both eyes were tested. Pupils and pupillary reactions were assessed in terms of size, reactivity to light and any abnormal reactions. If nystagmus was seen, its type was noted. The fundus examination of both eyes was done by direct ophthalmoscope to find out evidence of papilledema, optic atrophy, etc. CT/MRI was advised to confirm the diagnosis and location of ICSOL.
| Results|| |
[Figure 1] shows that the study constituted 36 (51.34%) males and 34 (48.57%) females.
In the study, 27.14% ICSOL was found in the age group of 31–40 years, followed by 22.86% in 41–50 years. The lowest incidence was found in the age group of 0–10 years, as shown in [Graph 1].
Age- and sex-wise distribution
[Graph 2] illustrates that >10 years and 31–40 years of age group have equal sex distribution. Male: female ratio was high in 21–30 years and 51–60 years age groups whereas female preponderance was seen in 11–20 and 41–50 years of age group. In 61–70 years of age group, sex ratio is 4:2.
Location of intracranial space-occupying lesion (computed tomography/magnetic resonance imaging-based)
Location wise 68.57% had supratentorial ICSOLs and less than a half, i.e., 31.43% had infratentorial. Intracranially, 25.72% of lesions presented in cerebellopontine (CP) angle followed by 22.85% in sellar, parasellar, and suprasellar region. ICSOLs involving more than two lobes of cerebrum were included in multilobar category which accounted for 12.86%. Among the five different lobes of cerebrum, 7.14% of patients had ICSOL in occipital lobe, 2.86% had in frontal lobe, and 1.43% in temporal lobe. None of the patients presented with isolated parietal lobe lesion instead, it was observed that ICSOL in the parietal lobe was present in coexistence with other surrounding lobes. The number of cases in CP angle does not match with the number of acoustic schwannoma count because CP angle region also includes meningioma of CP angle.
Spectrum of intracranial space-occupying lesion
Glioma and meningioma formed the major bulk of ICSOL contributing to 18.57% each of all patients. The next common was vestibular schwannoma also known as acoustic neuroma with 17.14% patients out of 70. Next in the frequency is pituitary adenoma with 11.43%, followed by 8.57% patients of chronic subdural hemorrhage, and 5.71% of craniopharyngiomas. About 2.85% of patients of epidermoid cyst, cavernous hemangioma, and tuberculoma each were present. Pineal gland involvement was found in 2 (2.85%) patients, of which 1 presented with pineocytoma and others with pineoblastoma. One patient each of hemangioblastoma, AV malformation, chordoma, neurocysticercosis, Langerhans cell histiocytosis, and metastasis [Graph 4].
Signs and symptoms
Forty-three (61.43%) patients presented with both ocular and nonocular complaints. 31.43% of patients presented with nonocular complaints, whereas 7.14% presented solely with ocular complaints.
[Graph 5] illustrates that among ocular symptoms, DOV was complained by 51.43% of patients. About 7.14% presented with double vision, 5.71% had loss of vision, 4.29% had drooping of eyelids, and 1.43% had protrusion of the eyeball.
[Graph 6] shows nonocular complaints in which headache with or without vomiting was presenting symptom in 71.43% patients. 24.29% had seizures, 17.14% had vertigo, and weakness of extremities was found in 14.29% patients. Ears, nose, and throat complaints such as hearing loss (11.43%), giddiness (11.43%), and tinnitus (10%) were also seen. Difficulty in speech was presented by 5.17%, paraesthesia of face in 4.29% and neck stiffness in 1.43% of patients. Maximum patients presented with more than one symptoms and signs. The most common ocular sign was papilledema in 44.29% of patients followed by visual field defect in 37.14% of patients. Other signs observed were nystagmus, pupillary defect, color vision defect, II, III, V, VI, and VIII nerve palsy.
The association of signs and symptoms with location
Location-wise distribution of symptoms was done, and it was found to be attributable to the site. [Graph 7] shows that out of 51.4% of DOV maximally, it was present in lesions in sella and suprasellar regions which correlated with the fact that optic chiasma is anatomically related to that site thus causing DOV. Loss of vision was 5.7% which was observed in CP angle, sella/suprasellar, pineal gland, and parasagittal lesions mostly secondary to optic atrophy. Diplopia was seen in 7.2% of patients mostly in sella/suprasellar lesions due to lateral rectus muscle palsy. Drooping of the eyelid in two patients of CP angle ICSOL and one patient of sellar/suprasellar region was seen.
The distribution of signs according to location is depicted in [Graph 8]. Papilledema was found to be 44.3%, i.e., the most common sign. Location-wise papilledema was present in 14 patients with CP angle lesion due to high chances of obstruction of aqueduct causing obstructing hydrocephalus. Visual field defect was 37.2% being the second-most common sign, again which was most commonly found in sellar/suprasellar lesions. Nystagmus, color vision defect, II, II, V, VI, and VIIth nerve abnormalities were the other signs noted, as shown in [Graph 8].
- Best-corrected visual acuity
[Graph 9] illustrates the BCVA of all patients in this study
- Visual field defects on perimetry
[Graph 10] depicts visual defects in 26 patients. In 20 patients, it was normal, 17 were uncooperative for the test, and in seven patients, it was not possible due to poor vision
- Referral pattern
Thirty out of 70 patients in our study first visited ophthalmologists at first place with presenting complaints such as headache and DOV, where they were diagnosed to have ICSOL and then further referred to neurosurgeon.
| Discussion|| |
The mean age in this study was 39.81 years. The youngest patient was 7 years and the oldest being 70 years. Mehrazin et al.'s study on epidemiology of primary intracranial tumor in Iran observed that average age at diagnosis was 33.9 years (standard deviation = 18.1) and the median age was 34 years. Male: female ratio was 1.05:1 showed negligible difference in male-female distribution. Similar results were observed by Nalawade and Javadekar. Maximum patients had CP angle ICSOLs followed by sella/suprasellar lesions. Madan et al. also show similar results with majority of ICSOL in perichiasmatic region (20%) and CP angle (18%). Like this study, Madan et al. also showed that supra-tentorial tumors were more common 77 (87.5%). In the study done by Divya, the incidence of glioma (25.49%) was found to be highest, followed by meningioma (11.76%) just like this study. The correlation of symptoms and site of ICSOL were established sufficiently. DOV in sellar/suprasellar region lesions was due to a variable amount of pressure exerted over the optic chiasma depending on its size. Diplopia was complained by 5 patients. Per se, it is a nonlocalizing symptom caused due to cranial nerve paresis due to raised intracranial pressure, so was the reason in our study too. Drooping of the eyelid in CP angle lesion was seen due to VII nerve palsy whereas in pituitary adenoma patient, it was seen due to III nerve involvement causing ptosis. On examination of patients of ICSOLs signs, elicited also helped localization of lesion. The triad of ICSOL is headache, vomiting and papilledema. Furthermore, in our study, papilledema was the most common ophthalmic sign. It was noted that papilledema is commonly seen in patients having CP angle lesions. ICSOLs of infratentorial region that arise from cerebellum and fourth ventricle tend to obstruct the flow of cerebrospinal fluid through the aqueduct of Sylvius thus increasing intracranial pressure. Studies conducted by Bokka and Padala showed that papilledema is of varied etiology of which ICSOL is the most come cause. Solanki et al. interpreted from their study that ICSOL was the most common cause of papilledema. Nystagmus was mainly found in patients with ICSOL affecting cerebellum. The cardinal signs of cerebellar tumors are unsteadiness of gait and ataxia, hypotonicity, and nystagmus. Cranial nerves examination was very helpful in locating the site of ICSOL. Pituitary tumors are associated with optic atrophy, although it is not invariable, especially when the growth is postchiasmal (Mc Connell and Mooney, 1938). The pallor is majorly due to ischemia and it may not necessarily be associated with a loss of function until the nerve fibers themselves are affected. Second most commonly affected nerve was Abducens nerve (6th). With raised ICT and long course of 6th nerve intracranially, it is prone to stretching over the tip of petrous bone thus producing false localizing sign. Visual field defects detection had played a very important role in finding site of ICSOL. Enlargement of blind spot in12.8% of patients was due to raised ICT. Bitemporal hemianopia in 5.71% of patients was related to pituitary gland ICSOLs. Junctional scotoma was seen in patient with meningioma of perichiasmatic region. Homonymous hemianopia was seen in 4 patients affecting optic tract in ICSOL of temporoparietal lobes and optic radiation in parieto-occipital lobes. Similarly, one patient with AV malformation feeding right posterior cerebral artery also presented with homonymous hemianopia. In this study, 42.85% of patients presented first to ophthalmologists and were then referred to neurosurgeons.
| Conclusion|| |
As the optic pathway covers a long distance as anterior as orbit to the posterior-most located occipital lobe, it is most commonly affected by intracranial lesions. Depending on the part of optic pathway affected eyes present with different signs and symptoms accordingly which helps precisely to localize the site of lesion. The most common presentation of ICSOL was a headache with or without true localizing signs and symptoms. Therefore, they land up presenting to ophthalmologists for their complaints. In such scenario, ophthalmologists should be keen to rule out ICSOL in such patients. Visual field testing and fundus examination along with visual acuity should be carried out in every patient complaining of disturbance of vision when no obvious ocular cause is found. Thus, ophthalmologists should be suspicious about ICSOL and have broad-spectrum view while treating such patients with headache which can be misdiagnosed simply as refractive error. Proper evaluation of symptoms and signs and detailed examination and investigations of ICSOL leads to early detection of ICSOL. Through our study, we want to aware that ophthalmologists are first to detect and play a major role in the early detection of most of the ICSOLs. Not all ICSOLs but good bulk first present to ophthalmologists before visiting a neurosurgeon, thus ophthalmologists at times also act as a guide for patients to approach an appropriate specialist for their illness. Early diagnosis helps patient to seek early treatment and prevent lifelong burden of untreatable consequences of the disease [Figure 2] and [Figure 3] and Graph 3].
|Figure 2: Location of intracranial space occupying lesion (computed tomography/magnetic resonance imaging based)|
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]