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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 56  |  Issue : 2  |  Page : 71-75

Profile of brain tumors having ocular manifestations in a Tertiary Eye Care Institute: A retrospective study


1 Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
2 Department of Ocular Pathology, Uveitis and Neuro-Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
3 Department of Vitreo-Retina Surgery, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
4 Department of Ophthalmic Plastic and Reconstructive Surgery, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
5 Department of Pediatric Ophthalmology and Strabismus, Sri Sankaradeva Nethralaya, Guwahati, Assam, India

Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Saurabh Deshmukh
Department of Ophthalmology, Sri Sankaradeva Nethralaya, 96, Basistha Road, Beltola, Guwahati - 781 028, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_49_18

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  Abstract 


Aim: To form a profile of brain tumors having ocular manifestations presenting to a tertiary eye care institute. Materials and Methods: The medical records of patients diagnosed with primary brain tumors between January 2012 and December 2017 were reviewed. Patients underwent a detailed ocular examination and neuroimaging to confirm the diagnosis. Results: Out of the 17 patients, 11 (65%) were female and 6 (35%) were male. The mean age was found to be 43.17 ± 11.04 years and the majority of the patients belonged to the age group 21—40 years (47.06%). The most common presenting symptom was found to be diminution of vision (100%), followed by headache (41.14%) and vertigo (23.52%). The most common sign was optic disc changes, namely optic atrophy (47.05%), followed by disc pallor (29.41%) and papilledema (11.76%). Meningioma (41%) was the most common tumor followed by pituitary macroadenomas (29%). At the time of presentation, two patients had the restriction of extraocular movements, seven patients had a positive relative afferent pupillary defect, and four had defective color vision. Conclusions: Ophthalmic signs and symptoms form a major part of the presentation in patients with intracranial tumors. Majority of the patients diagnosed by ophthalmologists with brain tumors presented with optic disc pallor or edema resulting in diminution of vision. By careful neuro-ophthalmic evaluation, early diagnosis of intracranial space occupying lesions can be made and prompt referral to neurosurgeon can reduce the morbidity and mortality.

Keywords: Intracranial tumors, neuro-ophthalmology, ophthalmic manifestation, visual fields, visual impairment


How to cite this article:
Deshmukh S, Das D, Bhattacharjee H, Kuri GC, Magdalene D, Gupta K, Multani PK, Paulbuddhe V, Dhar S. Profile of brain tumors having ocular manifestations in a Tertiary Eye Care Institute: A retrospective study. TNOA J Ophthalmic Sci Res 2018;56:71-5

How to cite this URL:
Deshmukh S, Das D, Bhattacharjee H, Kuri GC, Magdalene D, Gupta K, Multani PK, Paulbuddhe V, Dhar S. Profile of brain tumors having ocular manifestations in a Tertiary Eye Care Institute: A retrospective study. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2018 Oct 16];56:71-5. Available from: http://www.tnoajosr.com/text.asp?2018/56/2/71/238494




  Introduction Top


A primary brain tumor is one of the most common and important reasons for seeking neurological and ophthalmological consultation worldwide.[1],[2],[3] The clinical signs and symptoms and management of these tumors depends on the site, type, and duration of the tumor. The clinical features are related to mass effect, raised intracranial tension, or expression or suppression of various hormones by the tumors or due to hydrocephalus.[4],[5] These clinical presentations are caused due to the involvement of the visual pathway, including cranial nerves (CNs), their tracts, and cranial nuclei.[3],[5],[6],[7],[8],[9],[10],[11] Ophthalmic signs and symptoms include vision loss, ptosis, paresis or paralysis of extraocular movements, diplopia, and optic disc changes.[7] About 46.8%—88.6% of patients present with neuro-ophthalmological manifestations.[3],[7],[10],[11] About 60% of these patients with brain tumor present first to an ophthalmologist with ocular complaints.[12] Thus, the ophthalmologists play a crucial role in early diagnosis and appropriate referral to the neurosurgeon and endocrinologist. The purpose of this study was to form a profile of the intracranial tumors presenting to the neuro-ophthalmology clinic in a tertiary eye care institute.


  Materials and Methods Top


This retrospective study included 17 patients diagnosed with primary brain tumors at a tertiary eye care institute in Northeast India between January 2012 and December 2017 after approval by the institutional ethics committee. Medical records of each patient were reviewed. A detailed history was taken from the patient as well as from the attendants. Onset, duration, and progress of symptoms such as the blurring of vision, eye pain, headache with or without aura, vomiting, diplopia, proptosis, and drooping of eyelids were noted. History of illness, hypertension, diabetes mellitus, ischemic heart disease, asthma, tuberculosis, substance abuse, other medication, and infection were noted. The detailed ophthalmological examination was done including assessment of uncorrected visual acuity, pinhole vision, best-corrected visual acuity, ocular movements in all nine cardinal gazes, nystagmus, squint assessment using cover and alternate cover test, pupil examination for the relative afferent pupillary defect (RAPD), and color vision test (Ishihara's chart). Slit-lamp examination of anterior segment was done. Posterior segment was examined using slit lamp with +90 diopter lens and using indirect ophthalmoscope with +20 diopter lenses. Intraocular pressure was measured by Goldmann applanation tonometry. Diplopia charting was done for patients complaining of diplopia. Hess charting was done to measure the degree of deviation, torsion, and also for follow-up in all cases of diplopia. Any abnormality in head posture caused due to diplopia was noted. The palpebral apertures were compared and any abnormal widening because of lid retraction or proptosis was noted. If proptosis was detected, its measurement was taken and direction was noted. Similarly, a detailed examination was also done for ptosis. All the CNs were systematically examined. First CN was examined by testing each nostril separately for a sense of smell using the coffee beans. The second CN was assessed using the visual acuity, pupillary reactions, visual field assessment, and visualizing the optic nerve head. The third, fourth, and sixth CNs were assessed by examination of ocular motility in all nine cardinal gazes. Fifth CN, motor part was tested by palpating the temporalis and the muscles of mastication when the patient clenched his teeth and sensory part was tested by checking for sensations in all three dermatomes. The patient was asked to crease up the forehead, reveal the teeth, and puff out the cheeks to test for the seventh CN. Bell's phenomenon was also elicited. Weber's and Rinne's test were performed using tuning fork to check for the eighth CN. Ninth and tenth CN were tested by performing gag reflex and asking to patient say Ah and checking for the palatal arches. Eleventh CN was tested by asking the patient to shrug his shoulders against resistance and to rotate his head against resistance. Twelfth CN was tested by asking the patient to put out his tongue and observing for any wasting or deviation. Central nervous system examination was performed by checking for orientation and short and long-term memory. The tone in the muscles and reflexes were elicited. Coordination was tested using the finger-nose test and dysdiadochokinesis. Sensations were checked using pinprick test, temperature sense, vibration sense, and joint and position sense. Fundus and optic disc photography was done. Automated perimetry (Humphrey visual field 30-2, 10-2) was done for visual field defects. Visual evoked potential was done. To confirm the clinical diagnosis and ascertain the site of lesion, magnetic resonance imaging (MRI) of brain and orbit was performed.


  Results Top


A total of 17 patients were evaluated. The mean age was 43.17 ± 11.04 years. Of the 17 patients, 47.06% (n = 8) were in the 21—40 years' age group, 41.18% (n = 7) were in the 41—60 years' age group, and 5.88% (n = 1) each in 0—20 and 61 and above years' age group [Figure 1]a.
Figure 1: (a) Age group-wise distribution of patients. (b) Gender-wise distribution of patients

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Of the 17 patients, 64.71% (n = 11) were female and 35.29% (n = 6) were male [Figure 1]b. There were 100% female patients (n = 1) and 0% (n = 0) male patient in 0—20 years age group, 50% female patients (n = 4) and 50% male patients (n = 4) in 21—40 years' age group, 71.43% female patients (n = 5) and 28.57% male patients (n = 2) in 41—60 years' age group, and 100% female patients (n = 1) and 0% (n = 0) male patients in 61 years and above age group of patients.

The visual acuity of the worse eye was taken into account. The visual acuity was poor in most of the patients at the time of presentation, that is, 6/36 or less in 70.58% (n = 12) of the patients. 23.52% (n = 4) of the patients had a visual acuity of 6/6—6/12, and 5.88% (n = 1) had visual acuity between 6/12 and 6/36 [Figure 2].
Figure 2: Visual acuity at the time of presentation, number of patients, and percentage

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The patients presented with a wide variety of symptoms [Figure 3]a. All patients presented with diminution of vision (n = 17). The second most common symptom was a headache, present in 41.17% (n = 7) of the patients, followed by vertigo in 23.52% (n = 4), vomiting and tinnitus in 11.76% (n = 2) of the patients each. 5.88% (n = 1) patients presented with diplopia, facial swelling, epistaxis, arthritis, pallor, and ptosis each.
Figure 3: (a) Symptoms at the time of presentation. (b) Signs at the time of presentation

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The most common ocular sign which we observed was optic disc atrophy, seen in 47.05% (n = 8) of the patients. Optic disc pallor was seen in 29.41% (n = 5) and papilledema in 11.76% (n = 2) of the patients. One patient had retinal pigment epithelial defects and one had normal looking fundus. 11.76% (n = 2) of the patients showed restriction of extraocular movements. One patient had a restriction of movement in up gaze and one had a restriction in all gazes. RAPD was seen in 41.17% (n = 7) of the patients at the time of presentation. 23.52% (n = 4) of the patients had defective color vision at the time of presentation [Figure 3]b.

11.76% (n = 2) of the patients had a normal visual field. Quadrantanopia was seen in 5 (29.41%) patients, while 7 (41.18%) had hemianopia and 3 (17.65%) had a three quadrant or more visual field loss. [Figure 4].
Figure 4: Visual field defects at the time of presentation

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Meningioma was the most common tumor observed in this study, with a prevalence of 41.17% (n = 7). The next most common tumor encountered was pituitary macroadenoma, which was seen in 29.41% (n = 5) of the patients. Craniopharyngioma and posterior fossa tumor were seen in 11.76% (n = 2) of the patients. Intracranial space-occupying lesion (ICSOL) was seen in 5.88% (n = 1) of the patients [Figure 5].
Figure 5: Types of brain tumor found in the study

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  Discussion Top


Studies have shown that about 80% of primary brain tumors occur in adults and 20% in the pediatric age group.[13] Primary brain tumors are the second most common solid tumor in children. Approximately 70% of the brain tumors have glial cell origin whereas 15% of them originate from the meninges. The location of the brain tumor varies with age, in adults 70% are supratentorial, whereas in children 70% are infratentorial.[14] Among the neurological diseases, intracranial tumors are the second most common cause of death, first being the cerebrovascular accident.[1] In developing countries, these patients usually present very late with severe to complete visual loss from optic atrophy.[12] About 50% of patients who are diagnosed with primary brain tumors initially present with ophthalmic signs and symptoms.[12],[15]

The mean age of patients in this study was 43.17 years which is comparable to 42.8 years seen in the study conducted by Snyder et al.[16] The mean age in similar studies done in Iran and Kenya were 33.9 and 37 years, respectively.[1],[15] Thus, brain tumors affect mainly young adults and middle-aged individuals, the economically and physically active subset of the society. In children (age group 0—20 years), the prevalence was found to be 5.8% which is similar to results seen by Mehrazin et al.[1]

In our study, we found that there was female preponderance (11 females and 6 males) of brain tumors which is in contrast to the study by Snyder et al.[16] (65 males and 36 females) and Onakpoya et al.[12] (53 males and 35 females). Our study showed that majority of the patients were female, that is, a clear sex predilection which is comparable with other studies by Sefi-Yurdakul N.[17]

In this study, visual acuity of the worse eye was taken into account for statistical purposes. At the time of presentation, most of the patients had severe visual impairment. 70.58% (n = 12) of the patients had a visual acuity 6/36 or less. Of these 12 patients, 3 patients denied perception of light in the worse eye. Kaur et al. observed in their study that the degree of improvement is inversely related to the duration of symptoms.[18]

The signs and symptoms seen in patients with a brain tumor are a result of both local and generalized effects. Local effects include direct pressure over the neural pathways, vascular compromise, and abnormal nervous system stimulation producing seizures. Involvement of the motor system produces weakness. Tumors affecting the sensory area cause paraesthesia or numbness. The patients presented with a wide variety of symptoms. Diminution of vision was the most common ophthalmic symptom in this series, seen in all patients (100%). These results are similar to previous reports, that is, 88.6% and 86%.[10],[11] Involvement of the vision is because of mass-compression effect on the optic nerve, the optic chiasma, or the optic tract. Headache was the second most common symptom observed in 41.17% of the patients for which they sought the medical help. It is a common symptom manifesting in about 43% to 99% of patients with brain tumor.[10],[15],[19] Other symptoms reported were vertigo, vomiting, tinnitus, diplopia, facial swelling, epistaxis, arthritis, pallor, and ptosis.

The most common ocular sign observed on fundus examination was optic disc atrophy, seen in 47.05% of the patients. Onakpoya et al. in their study found optic disc atrophy and papilledema in 44.4% of the patients, which is in line with the results of our study.[12] Optic disc pallor was seen in 29.41% and papilledema in 11.76% of the patients. Papilledema was reported in 27.7% and 46.8% of patients with intracranial tumors in studies conducted at New York and Romania, respectively.[7],[16] These findings highlight the importance of ophthalmoscopy in neuro-ophthalmology examination in the patients with brain tumor. Tumors located anteriorly have a higher tendency to cause optic nerve compression which can be easily observed on ophthalmoscopic examinations.[15] In our study, 2 (11.17%) patients had extraocular movement restriction which is similar to study by Onakpoya et al.[12] Mass effect or infiltration by the tumor can affect ocular nerves causing gaze restriction and diplopia. RAPD is an important early sign of unilateral optic nerve compression that is seen in almost half the patients with brain tumor. Similar to other studies, the prevalence of RAPD in our study was 41.17%.[10],[15]

Visual field defects arise as a result of disruption of the visual pathway. Their pattern depends on the location of the tumor. In our study, hemianopia was found to be the most common visual defect, followed by quadrantopia. The hallmark field defect seen in pituitary tumors is bitemporal hemianopia.[20] The typical visual field defect, bitemporal hemianopia, is due to the anatomical compression of the optic chiasma, which contains the crossing nasal fibers of each optic nerve.[21] In our study, similar findings were seen, five patients with pituitary macroadenoma had bitemporal hemianopia. Trautman et al. detected that visual fields are affected more often than visual acuity.[22]

Meningioma was the most common tumor observed in this study, with a prevalence of 41.17%. Onakpoya et al. also found meningiomas to be the most common brain tumor with a prevalence of 36.4%.[12] The next most common tumor encountered was pituitary macroadenoma followed by craniopharyngioma and posterior fossa tumor. In contrast to our study, Tagoe et al. found pituitary adenoma to be the most common brain tumor with a prevalence of 55.5% followed by meningioma 27.8%.[23]

Strengths and limitations

One of the limitations of our study is its retrospective nature. Second, only data that have been recorded previously in medical records were available. There may have been other signs and symptoms that were not recorded. Third, we only analyzed the patients who were diagnosed to have a brain tumor, and we did not analyze patients who had signs such as optic nerve pallor or swelling that did not have brain lesions. Moreover, follow-up of the patients was not available, as to what surgery the patient underwent and what the outcome was, as after the MRI diagnosis they were referred to and managed by outside facilities. However, despite these limitations, we do define the profile of brain tumors and emphasize the importance of a complete neuro-ophthalmological examination to identify them.


  Conclusions Top


Ocular features can be considered as a window through which we can detect brain lesions. Early detection of a brain tumor through ocular signs and symptoms can help in early diagnosis and appropriate management. All the patients presenting with diminution of vision and with fundus findings must undergo visual field examination. MRI must be performed in doubtful cases to delineate the exact anatomical location and diagnosis of the lesion. Prognosis of the patients is much better if the lesion is detected early and treated appropriately. Thus, ophthalmologists play an important role in saving the life and vision of these patients.

Acknowledgment

We would like to thank Sri Kanchi Sankara Health and Educational Foundation, Guwahati, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Marco S, Karimurio J, Kariuki M, Lubanga P. Visual loss and ocular involvement in adult patients with intracranial neoplasms in Kenyatta national hospital, Nairobi, Kenya. East Afr J Ophthalmol 2007;13:15-20.  Back to cited text no. 15
    
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Tagoe NN, Essuman VA, Fordjuor G, Akpalu J, Bankah P, Ndanu T, et al. Neuro-ophthalmic and clinical characteristics of brain tumours in a tertiary hospital in Ghana. Ghana Med J 2015;49:181-6.  Back to cited text no. 23
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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