Bitemporal hemianopia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-In-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Template:NIHASRAJA

Synonyms and keywords: Bitemporal hemianopsia

Overview

Bitemporal hemianopia (bi-: both eyes, temporal: temporal/peripheral, hemi-: half, anopsia: blindness) is defect in visual pathway causing loss of sight in the outer half of the visual field. A lesion compressing or disrupting optic chiasm would result in bitemporal hemianopia. Additional symptoms such as Headache, Diplopia, Endocrine disorders can be present. Most common causes are Pituitary macroadenoma, Craniopharyngioma, Meningioma and Aneurysm of anterior communicating artery. Visual field defects can be diagnosed using Standard Automated Perimetry (SAP). CT Imaging and MRI usually reveal the underlying cause. While vision loss can be improved by treating the underlying cause, sometimes it can be permanent.

Historical Perspective

  • First case of Bitemporal hemianopsia was reported by Clarence A. Veasey, in 1904 [1].
  • In 1929, L.S.Kubie and J.W.Beckmann documented Diplopia to be the most reported symptom in patients with bitemporal hemianopia in the absence of extraocular muscle palsies.[2]

Classification

  • Bitemporal hemianopia may be classified according to the number of defective optic fibers into complete bitemporal hemianopia and partial bitemporal hemianopia.

Pathophysiology

Comparison of visual field and retinoptic field. Picture courtesy Nihas R Mateti
Comparison of visual field and retinoptic field. Picture courtesy Nihas R Mateti


Causes

Common Causes

Most of the common causes of bitemporal hemianopia are due to disorders of the pituitary gland and its surrounding structures.

Causes by Organ System

Cardiovascular No underlying causes
Chemical / poisoning No underlying causes
Dermatologic Dermatochalasis[11]
Drug Side Effect Chloroquine retinopathy[12], Ethambutol toxicity[13]
Ear Nose Throat No underlying causes
Endocrine Pituatary macroadenoma, Prolactinoma
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal / Ortho No underlying causes
Neurologic Craniopharyngioma, Aneurysm of anterior communicating artery, Intracranial vascular loop, Meningioma, Enlarged third ventricle[14], Glioma of third ventricle[15], Chronic chiasmal arachnoiditis[16], Suprasellar tumors[17][17][17][17][17][17][17][17][17][17][17][17][17][17][17][17][17][14][13][13][13][13][13][13], Adamantinoma of sella turcica[17], Optic neuropathy[13][13][13][13][13][13][13][13][13][13][13][13][13][13][13][13][13][8][7][7][7][7][7][7], Traumatic chiasmal syndrome[18], Dolichoectasia of internal carotid arteries[19]
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic Hypophyseal hypertrophy in pregnancy[20]
Oncologic Adamantinoma of sella turcica, Craniopharyngioma, Glioma of third ventricle, Pituitary macroadenoma, Prolactinoma, Meningioma, Suprasellar tumors
Opthalmologic Dermatochalasis, Optic neuropathy, Optic chiasmal syndrome, Bilateral blepharoptosis[21], Traumatic chiasmal syndrome, Retinal disorders[22], Nasal Staphylomata [23], Tilted disc syndrome[24]
Overdose / Toxicity Ethambutol toxicity
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy No underlying causes
Sexual No underlying causes
Trauma Traumatic chiasmal syndrome
Urologic No underlying causes
Dental No underlying causes
Miscellaneous No underlying causes

Differentiating Bitemporal hemianopia from other Diseases

Differential diagnosis of Bitemporal hemianopia

Pituitary adenoma Functional adenoma - Endocrine abnormalities, Non functional adenoma - exert pressure symptoms (Headache). Isointense on MRI.
Suprasellar tumors Craniopharyngioma Headache, Seizure, Focal neurological deficit. Calcified mass with Motor oil like fluid within the tumor on MRI.
Aneurysm of anterior communicating artery Unruptured aneurysm can be asymptomatic or mild headache. Ruptured aneurysms presents with 'Worst headache of life' (Subarachnoid hemorrhage), Seizures, Focal neurological deficit.
Meningioma Headache, Seizure, Focal neurological deficit. Well circumscribed, Extra-axial mass with Dural attachment on MRI. Psammoma bodies on immunohistopathology.

Epidemiology and Demographics

  • The prevalence of pituitary adenoma is approximately 16.7% worldwide. Pituitary adenomas are almost always associated with bitemporal hemianopia.[25]
  • There is no racial predilection to bitemporal hemianopia.

Risk Factors

  • There are no established risk factors for bitemporal hemianopia.

Screening

  • There is insufficient evidence to recommend routine screening for bitemporal hemianopia in a normal population.
  • Patients with asymptomatic pituitary adenomas can be screened by automated perimetry.
  • Presence of Vertical step [SN-96% SP-100%] and Temporal depression[SN-100% and SP-98%] is the criteria for diagnosis of bitemporal hemianopia. [26]

Natural History, Complications, and Prognosis

Natural History

  • In most of the patients, central visual field of 110°–120° (using Goldmann perimetry) is preserved and is sufficient for day to day activities. A volume perimetry demonstrates a binocular scotoma beyond the point of fixation.[27]

Complications

Prognosis

Diagnosis

Diagnostic Study of Choice

Bitemporal hemianopsia Nihas
Bitemporal hemianopsia. Picture courtesy by Nihas R Mateti.



History and Symptoms

Physical Examination

  • Physical examination of patients with bitemporal hemianopia is usually normal.

Laboratory Findings

  • There are no diagnostic laboratory findings associated with bitemporal hemianopia.

Electrocardiogram

  • There are no ECG findings associated with bitemporal hemianopia.

X-ray

  • There are no x-ray findings associated with bitemporal hemianopia.

Echocardiography or Ultrasound

  • There are no echocardiography/ultrasound findings associated with bitemporal hemianopia.
  • However, B-scan ultrasonography may be helpful in the diagnosis of bitemporal hemianopia when etiology is Nasal staphylomata.[23]

CT scan

  • Brain CT scan showing a mass near optic chiasm may be helpful in the identifying underlying cause of bitemporal hemianopia.
  • Calcifications can be seen in craniopharyngiomas.[37]
  • Menigiomas are moderately hyperdense before contrast enhancement and have no or minimal calcification.[38]

MRI

  • Brain MRI showing a mass near optic chiasm may be helpful in the identifying underlying cause of bitemporal hemianopia. Compression of optic chiasm by tumor can be graded from 0-4.[26]
  • Extent and the relation of craniopharyngioma to other structures can be clearly seen in MRI than CT scan.[37]

Treatment

Medical Therapy

Radiation Therapy

  • Radiation therapy can be used as an adjuvant to medical therapy and surgical therapy to prevent remission.
  • Gamma-knife therapy has seen a recent success in normalizing hormonal hypersecretion in patients who are not suitable candidates for surgery. A 90.3% tumor control had been achieved in microdenomas.[41][42]
  • Stereotactic radiosurgery is being considered in the treatment of parasellar meningiomas.[43]

Surgery

  • Surgery is the mainstay of treatment for bitemporal hemianopia.
  • Pituitary adenoma:
    • Transsphenoidal pituitary surgery is the first line surgery for pituitary adenomas. Visual improvement occurs in 87% of those with preoperative visual loss. It has a mortality rate of 0.5%.[44]
    • A meta-analysis of endoscopic vs microscopic surgery hasn't been statistically significant but endoscopic route has been attributed to increased vascular complications.[45]
  • Meningioma:
    • A fronto-orbital approach for tumor excision is preferred. Visual defect has been resolved post-operatively.[9]

Primary Prevention

  • There are no established measures for the primary prevention of bitemporal hemianopia.

Secondary Prevention

  • There are no established measures for the secondary prevention of bitemporal hemianopia.

References

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  2. Kubie, L. S.; Beckmann, J. W. (1929). "DIPLOPIA WITHOUT EXTRA-OCULAR PALSIES, CAUSED BY HETERONYMOUS DEFECTS IN THE VISUAL FIELDS ASSOCIATED WITH DEFECTIVE MACULAR VISION". Brain. 52 (3): 317–333. doi:10.1093/brain/52.3.317. ISSN 0006-8950.
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