Predictors of visual outcomes in urgent or delayed pituitary macroadenoma resection

Predictors of visual outcomes in urgent or delayed pituitary macroadenoma resection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictors of visual outcomes in urgent or delayed pituitary macroadenoma resection Marko (Chi-Wei) Tien, Lauren Pickel, Alexandre Boutet, Yash Patel, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7521873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Visual recovery after pituitary macroadenoma decompression is unpredictable. We sought to identify clinical and radiologic predictors of visual recovery and explore visual outcomes in patients who underwent early versus late surgery. Methods: Retrospective study of patients with pituitary macroadenomas approaching/contacting the chiasm at a tertiary neuro-ophthalmology practice. Clinical/demographic/MRI data was analyzed. Patients who were observed or received surgery after 1 year were identified. A final visual acuity (VA) of at least 20/40 and a final visual field mean deviation (VF MD) of -5dB or better were defined as positive outcomes. Results: 68 patients were included. Patients with positive VA outcomes had better preoperative VA (logMAR 0.3 vs 1.3), VF MD (-8.1dB vs -17.9dB), thicker retinal nerve fiber layer (RNFL) (81.9µm vs 69.5µm) and ganglion cell complexes (GCC) (69.0µm vs 50.5µm) than those without. VF outcomes were predicted by better preoperative VA (logMAR 0.3 vs 0.7), VF MD (-7.4dB vs -14.5dB), thicker RNFL (84.1µm vs 70.5µm) and GCC (71.2µm vs 55.6µm) measurements, and tumour volume (8.4cm 3 vs 18.2cm 3 ). 30 patients with better VA (logMAR 0.2 vs 0.7), VF MD (-3.97dB vs -12.61dB), thicker RNFL (88.7µm vs 76.5µm), and GCC (74.3µm vs 64.6µm) measurements had surgery deferred. Visual outcomes were similar compared to those who had surgery within a year. Conclusion: Preoperative VA/VF MD/RNFL/GCC thickness may predict visual outcomes after pituitary macroadenoma resection. Future studies are required to evaluate the safety of deferring surgery, even with favourable preoperative visual parameters. ganglion cell complex magnetic resonance imaging pituitary macroadenoma retinal nerve fiber layer visual recovery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Pituitary adenomas are among the most common intracranial neoplasms, comprising a diverse group of tumours arising from the pituitary gland. 1 Although typically benign, 2 they can cause significant morbidity through hormonal hypersecretion or local invasion. 3 Vision loss is a common presenting feature and occurs through two main processes. Blockage of signal conduction at the optic chiasm can cause rapid but potentially reversible vision loss. Secondly, physical compression of the optic apparatus disrupts axo-plasmic flow via anterograde and retrograde degeneration of retinal ganglion cells with potentially irreversible blindness. 4 Optical coherence tomography (OCT) is a non-invasive, non-ionizing imaging modality readily available in most ophthalmic practices that can visualize retrograde degeneration as thinning of the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC). The visual pathway can be decompressed through surgical resection of the tumor, but recovery of vision is variable and complicates the decision to undergo surgery in asymptomatic patients. 5 , 6 Several factors have been proposed to influence visual outcomes including age, severity of preoperative visual deficit, tumour size, RNFL thickness, and GCC thickness, which may be the most sensitive predictor. 7 – 12 GCC loss directly corresponds to axonal damage, and greater preoperative GCC thickness has been correlated with postoperative visual field (VF) improvement. 12 – 14 Magnetic resonance imaging (MRI) is a key tool for surgical planning. Preoperative tumour volume may predict final visual outcomes, 7 but other findings such as volume of the optic chiasm and extent of suprasellar invasion have been associated with visual recovery. 15 – 17 To our knowledge, few studies have directly compared the relative prognostic value of OCT and MRI features of pituitary adenomas to predict postoperative visual recovery. Several studies have demonstrated an association between thinner preoperative RNFL measurements with greater suprasellar extension and optic chiasm compression. 18 , 19 No studies have otherwise correlated MRI characteristics with ganglion cell analysis and investigated whether MRI or OCT findings more strongly predict visual outcomes. Thus, our study sought to correlate MRI and OCT measurements with vision outcomes in patients with pituitary adenomas post-transsphenoidal resection. We also sought to identify clinical and imaging factors in patients who deferred operative management by one year and characterize their visual outcomes. Methods This retrospective cohort study was conducted by the Departments of Neurosurgery, Medical Imaging, and Ophthalmology & Vision Sciences with approval from the University of Toronto Research Ethics Board and adhered to the Declaration of Helsinki. Informed consent was waived given the retrospective nature of the study. Patients from a single tertiary neuro-ophthalmology clinic diagnosed with non-functioning pituitary macroadenoma through clinical presentation, hormonal profile, and radiologic investigations were identified between January 1, 2008, and September 30, 2024. Inclusion criteria were non-secretory tumors approaching or contacting the optic chiasm as evidenced on dedicated MRI of the sella. Exclusion criteria included a history of previous pituitary surgery/radiotherapy or confounding ophthalmic disease affecting the optic nerve or retina apart from compressive optic neuropathy. Demographic data collected included age and gender. Clinical measures included best-corrected visual acuity (VA), VF mean deviation (MD) measured by Humphrey 24 − 2 perimetry, and the appearance of the optic nerve on fundoscopy (normal, temporal pallor, diffuse pallor, edema). Spectral-domain OCT was performed to measure the average thicknesses of the RNFL and of the nasal, temporal and overall GCC. All clinical measures were collected at initial presentation and 6 months postoperatively or sooner if no later follow-up was available following surgery, or at the 1-year follow-up appointment if no surgery was pursued. Positive VA outcome was defined as a final VA of 20/40 or greater. Positive VF outcome was defined as a final VF MD of -5dB or better. Measurements were taken from both eyes in all patients when appropriate. MRI sella (voxel size: 0.5 x 0.5 x 2mm) or brain MRI (voxel size: 1 x 1 x 1mm) were acquired within 6 months preoperatively and at 1 year postoperatively or sooner. Using preoperative contrast images when available, otherwise T2-weighted images, a semi-automated method was used for tumor segmentation to obtain their preoperative volume ( https://www.slicer.org/ ): first the Otsu threshold was applied to isolate tumor regions by creating an optimal binary thresholded image that separates an image into foreground and background components, 20 then the grow from seeds module was used to generate a 3D segmentation, which was manually adjusted in all planes by LP and then verified for accuracy by AB (board certified neuroradiologist) (Fig. 1 ). In addition to volume, maximum anteroposterior, craniocaudal, and transverse dimensions of tumors were measured from coronal or sagittal sections. Postoperative tumor residual was defined as none (nonvisible), minimal (millimetric soft tissue), and gross residual (nodular obvious residual) on postoperative MRI scans. Semi-quantitative visual assessments of relationships with optic apparatus and the cavernous sinuses were performed for the pre- and postoperative MRI. For optic nerves (right and left) and chiasms, the mass was considered to be separate from, abutting, or displacing them. Cavernous sinus invasion was defined as a Knosp classification of grade 3 or greater. Similar to tumor segmentations, these were generated by LP and verified for accuracy by AB (board certified neuroradiologist). Descriptive and inferential statistics were conducted using IBM SPSS Statistics (ver. 29.0.1.0). Continuous variables were reported as mean values with a range and standard deviation (SD). Analysis of variance (ANOVA) was conducted to assess for relationships between continuous data and VA/VF outcome. Chi-Square with Bonferroni correction was performed to identify associations between categorical variables. Pearson’s coefficient ( r ) and point biserial correlations were calculated to characterize correlations between study variables and VA/VF outcome, and Fisher’s z-transformation was used to identify significant differences in correlation coefficients. Receiver-Operating Characteristic (ROC) curve analysis was conducted to assess the utility of preoperative RNFL/GCC thickness in predicting VA and VF MD outcomes. The areas under the curve (AUCs) were calculated and compared using the methods described by Delong et al. 21 Cutoff points maximizing the sensitivity and specificity were identified using the Youden Index ( J ). 22 All figures were created in IBM SPSS Statistics and edited in GIMP. Results 68 patients were included in the study. 38 underwent surgery within a year of presentation, while 30 either did not have surgery after one year of follow-up or had surgery after at least one year. At the time of data collection, a total of 44 patients had undergone transsphenoidal resection. Of the entire cohort, 30 patients were female, and the mean age was 53.3 years (SD 1.89, range 20 to 85). Average follow-up interval was 97.0 weeks (SD 8.8, range 8.0 to 344.6). Further baseline clinical characteristics are outlined in Table 1. Of the 44 patients who underwent surgery, 36 had preoperative and 34 had postoperative MRI available to review (Table 2). Eyes achieving a positive VA outcome demonstrated better preoperative VA (0.3 vs 1.3, P =.02), VF MD (-8.1dB vs -17.9dB, P =.03), thicker RNFL (81.9µm vs 69.5µm, P =.01) and thicker overall GCC (69.0µm vs 50.5µm, P <.001), nasal GCC (64.6µm vs 49.3µm, P =.01), and temporal GCC (73.4µm vs 52.5µm, P <.001) sectors than eyes achieving a poor VA outcome. Eyes achieving a positive VF outcome also demonstrated better preoperative VA (0.3 vs 0.7, P =.05), VF MD (-7.4dB vs -14.5dB, P <.001), thicker RNFL (85.1µm vs 70.5µm, P <.001) and thicker overall (71.2µm vs 55.6µm, P <.001), nasal (66.5µm vs 52.4µm, p<0.001), and temporal GCC (75.9µm vs 59.4µm, P <.001) sectors than eyes with a poor VF outcome. Smaller tumor volume (8.4cm 3 vs 18.2cm 3 , P =.024) and younger age at surgery (49.1 years vs 60.3 years, p =.017) were also associated with positive VF outcomes. The rest of the MRI characteristics investigated including optic nerve/chiasm involvement, residual tumor volume, maximal dimension of the tumour, and invasion into the cavernous sinus were not significantly associated with visual outcomes. Both RNFL and GCC thickness correlated with positive VA ( r =0.28 (95% CI [0.068, 0.47]) P =.01; 0.41 (95% CI [0.18, 0.60]) P <.001) and positive VF outcomes ( r =0.44 (95% CI [0.24, 0.60]) P <.001; 0.57 (95% CI [0.37, 0.72]), P <.001) (Figure 2); however, equivalence testing did not reveal a significant difference between RNFL and GCC correlation coefficients ( P =.4 and .3 for VA and VF respectively). Tumor volume significantly correlated with positive VF outcome ( r =-0.39 (95% CI [-0.64, -0.056]), P =.024) but not with positive VA outcome ( r =-0.33 (95% CI [-0.60, 0.0058]), P =.054) (Figure 3). Tumor volume also correlated with RNFL thickness ( r= -0.45 (95% CI [-0.69, -0.11]), P= .011) and GCC thickness ( r= -0.46 (95% CI [-0.73, -0.067]), P= .024). ROC curves for RNFL/GCC thickness predicting VA/VF outcomes are shown in Figure 4. All AUCs ranged between 0.8 and 0.86, except for the ROC curve of preoperative RNFL thickness predicting VA outcome with an AUC of 0.73. Differences between AUCs were not statistically significant ( P ’s>0.1). Cutoff points of preoperative RNFL thickness was 73.5µm ( J max =0.46) for predicting positive VA outcome and 77.0µm ( J max =0.58) for predicting positive VF outcome. Cutoff points of preoperative GCC thickness were 56.5µm (overall, J max =0.71), 56.3µm (nasal, J max =0.47) and 64.5µm (temporal, J max =0.68) for predicting positive VA outcome and was 59.5µm (overall, J max =0.51), 51.5µm (nasal, J max =0.46) and 66.8 (temporal, J max =0.51) for predicting positive VF MD outcome. Among 22 patients with a preoperative VA of 20/50 or worse, preoperative RNFL thickness ( r =0.63 (95% CI [0.28, 0.83])) and preoperative GCC thickness (overall ( r =0.63 (95% CI [0.16, 0.87])), nasal ( r =0.55 (95% CI [0.023, 0.84])), and temporal ( r =0.69 (95% CI [0.25, 0.89]))) were correlated with an improvement in VA to 20/40 or better after surgery. Cutoff points predicting improvement to 20/40 or better were 60.0µm ( J max =1.0) for preoperative RNFL thickness 53.0µm (overall, J max =0.92), 51.5µm (nasal, J max =0.83) and 54.8.5µm (temporal, J max =0.92) for preoperative GCC thickness. Among 35 patients with a preoperative VF of -5dB or worse, preoperative RNFL thickness ( r =0.52 (95% CI [0.21, 0.73])) and preoperative GCC thickness (overall ( r =0.73 (95% CI [0.45, 0.88])), nasal ( r =0.64 (95% CI [0.30, 0.84])), and temporal ( r =0.74 (95% CI [0.47, 0.89]))) were correlated with an improvement in postoperative VF to -5dB or better. RNFL and GCC (overall, nasal, temporal) thickness cutoff points predicting return of VF to -5dB or better were 67.5µm ( J max =0.57) and 61.0µm (overall, J max =1.0), 50.8µm (nasal, J max =0.86) and 69.8µm (temporal, J max =1.0), respectively. Multiple regression analyses did not identify a factor most predictive of VA or VF recovery in patients with an already poor preoperative VA or VF. Of the 30 patients who had surgery deferred, observation was recommended as the tumor was abutting the chiasm but not producing visual deficits in 15 and was approaching but not contacting the chiasm in 11. 2 patients requested observation, one experienced delay in seeing the neurosurgical team, and one could not undergo surgery due to medical instability. In all patients who had surgery deferred, a joint decision was made between the patient, neurosurgical, and neuro-ophthalmologic teams to maintain close follow-up with serial MRIs, VF/OCT imaging, and visual assessments in accordance with local practice guidelines. There was no significant difference in the proportion of patients who recovered VA to 20/40 ( P =.69) or VF to -5dB or better ( P =.10) in the worse-seeing eye between patients who had surgery within one year and those who did not. Those who had surgery deferred, in the worse-seeing eye, had better presenting VA (0.16 vs 0.65, P =.001), VF MD (-3.97dB vs -12.61dB, P <.001), thicker RNFL (88.7µm vs 76.5µm, P =.005), thicker overall (74.3µm vs 64.6µm, P =.017) and nasal GCC sectors (74.7µm vs 60.5µm, P <.001) than those who had surgery within one year (Table 3). Discussion This study investigated the clinical and MRI parameters associated with visual outcomes following early or delayed resection of pituitary macroadenomas approaching or contacting the chiasm. Similar to previous studies, preoperative VA, VF MD, RNFL/GCC thickness and tumor volume were associated with positive VA and VF outcomes. Even in those with poor preoperative vision, RNFL and GCC thickness are correlated with visual recovery. Furthermore, patients who had surgery deferred by a year were closely followed by both neurosurgical and neuro-ophthalmologic teams and had similar visual outcomes as those who received surgery within 1 year of presentation. Once chiasmal compression from pituitary macroadenomas induces nerve atrophy, vision loss may be permanent. For this reason, RNFL thinning is strongly prognostic of poor visual recovery. Several studies have previously demonstrated the relationship between RNFL thickness and post-surgical visual recovery. 23 – 25 Ganglion cell inner plexiform layer thickness has also recently gained interest as a predictor of visual recovery, though results are mixed. 11 , 25 – 27 Few if any large-scale studies have directly compared the prognostic value between RNFL and GCC thickness in patients with pituitary macroadenomas. Our findings are in line with previous work which has demonstrated poor visual outcomes in patients with thinner preoperative RNFL and GCC thicknesses. Furthermore, our equivalence testing showed that the relative strength of the correlation between visual outcomes and RNFL versus GCC thicknesses are similar (Fig. 2 , Fig. 4 ) and ROC analysis identified cutoff points of preoperative RNFL and GCC thicknesses in predicting VA/VF outcomes, suggesting that either may be used as a prognostic marker. Though OCT imaging is commonplace in most ophthalmology clinics, ganglion cell analysis software may not be readily available, especially in low-income countries where the costs of an OCT machine with advanced software may be inaccessible. Therefore, basic RNFL analysis may provide similar prognostic capabilities to GCC analysis in predicting visual outcomes after surgical decompression of pituitary macroadenomas. RNFL thickness and tumour volume were correlated with one another as seen in previous studies. 18 , 19 Additionally, we show that GCC thickness is also correlated with tumour volume. Compression of the visual apparatus induces retrograde degeneration of retinal ganglion cells which becomes apparent as thinning of the macular GCC and peripapillary RNFL. While some preliminary studies have demonstrated higher sensitivity of GCC thinning in detecting chiasmal compression over RNFL thinning, future studies may further investigate whether chiasmal compression is detected earlier on GCC or RNFL analysis. 28 Certain MRI findings such as pituitary tumour size, degree of suprasellar extension, and volume of the optic chiasm have been reported as prognosticators of visual recovery. 15 – 17 We demonstrated a correlation between tumour volume and positive VF outcome, but not with positive VA outcomes. One explanation for this finding is that the shape of the tumour may affect VA more than its absolute volume. One study demonstrated that the tumour height above the sella may influence VA recovery more than overall tumour volume. 29 Furthermore, the soft consistency of pituitary adenomas may not exert sufficient compressive forces on the macular fibers to cause dysfunction depending on the tumour’s shape. 30 We were also unable to find an association between perceived chiasm/optic nerve compression and visual outcomes. Therefore, sole visual interpretation of pituitary adenomas, especially those which are atypically shaped, may be a limited predictor of visual outcome unless there is marked compression or apoplexy. Surgery is often indicated when hormonal or visual deficits are present; however, asymptomatic large growing tumors may also be operated on to prevent future blindness. 31 Surgery itself can induce hormonal derangements and vision loss through damage to nearby structures; thus, the decision to operate must be balanced by the potential harms and benefits. 32 Though no studies to our knowledge have previously investigated the visual outcomes of early versus late pituitary decompression, several have demonstrated similar visual outcomes following early versus late surgical management of pituitary apoplexy. 33 , 34 The role of early versus late radiotherapy for adjuvant treatment has also been explored, with one study demonstrating no significant differences in development of endocrinopathies or permanent visual deficits between patients who received early or delayed adjuvant radiotherapy. 35 Others have shown that early adjuvant radiotherapy within 6 months of resection reduced tumour recurrence rates and decreased the risk of developing endocrinopathies; however, visual outcomes were not evaluated. 36 , 37 The decision to defer surgery is dependent on the degree of preoperative visual compromise and structural damage to the optic apparatus; however, other factors such as tumor progression, surgical complexity, and endocrine dysfunction may warrant more urgent management despite favourable preoperative visual parameters. In our study, the decision to observe or pursue surgery was based on multiple factors including but not limited to tumor size and its spatial relation with the optic chiasm, presence of visual deficits and optic atrophy, tumor growth rate, and the medical status and wishes of the patient. Those who were not immediately scheduled for transsphenoidal resection were closely monitored by both neurosurgical and neuro-ophthalmologic teams, and the decision to undergo surgery was revisited at each follow-up. Of those who happened to have surgery deferred by at least a year, we found no significant differences in visual outcomes compared to patients who received primary surgical resection of non-functioning pituitary macroadenomas within one year of presentation. Further prospective studies with larger cohorts are required to determine whether deferring surgical resection of pituitary adenomas can be advisable in certain cases. Limitations There were several limitations to our study. Firstly, MRI was not available to review for all patients. Secondly, many of our MRI parameters were obtained using semi-quantitative measures to replicate standard-of-care neuroradiology interpretations. This may have limited our ability to draw statistical associations, for example between visual outcomes and the relationship of the pituitary macroadenoma with the optic chiasm. Finally, we did not specifically investigate postoperative visual decline and the intraoperative factors that may influence vision loss after transsphenoidal resection as we did not have access to operative reports for all patients, nor did we have enough patients who experienced visual decline greater than 2 Snellen lines or worsening of VF MD by at least 2dB. We also wish to stress the importance of considering clinical, radiologic, and hormonal factors when deciding which patients require urgent pituitary decompression and which patients can be observed. In all cases, patients should be closely monitored by neurosurgical and neuro-ophthalmologic teams and the decision to pursue surgery should be revisited at each follow-up considering changes to the patient’s status or tumor characteristics. Future multi-center studies with larger, more heterogenous cohorts, and longer follow-up periods may offer further information to guide clinicians and surgeons in their discussions with patients on balancing the risks of vision loss from surgery versus from delaying treatment. Conclusions In summary, we demonstrated several predictors of VA and VF outcomes after transsphenoidal resection of pituitary macroadenomas, including age, preoperative VA/VF MD, RNFL/GCC thickness, and tumour volume. RNFL, GCC, and tumour volume were similarly powerful prognostic factors for the prediction of visual outcomes, though tumour volume was significantly associated only with VF and not VA outcomes. While it may be appropriate for some patients with favourable preoperative visual parameters to defer surgery, further prospective studies are needed to assess the safety and long-term effects of deferred surgery on tumor progression, surgical complexity, and endocrine function. Declarations None of the authors have any relevant conflicts of interest to disclose. Conclusion Preoperative VA/VF MD/RNFL/GCC thickness may predict visual outcomes after pituitary macroadenoma resection. Future studies are required to evaluate the safety of deferring surgery, even with favourable preoperative visual parameters. Author Contribution E.M., A.K., and A.B. conceptualized and oversaw the study. M.T., L.P., Y.P., M.M., R.L. collected patient data. M.T. and L.P. analyzed the study data. M.T. and L.P wrote the main manuscript text. M.T. created the tables and figures. All authors reviewed the manuscript prior to submission. Data Availability Data is provided within the manuscript and can be made available through the first author upon reasonable request. References Scheithauer BW, Gaffey TA, Lloyd RV et al (2006) Pathobiology of Pituitary Adenomas and Carcinomas. Neurosurgery 59(2):341. 10.1227/01.NEU.0000223437.51435.6E Ezzat S, Asa SL, Couldwell WT et al (2004) The prevalence of pituitary adenomas. Cancer 101(3):613–619. 10.1002/cncr.20412 Melmed S, Kaiser UB, Lopes MB et al (2022) Clinical Biology of the Pituitary Adenoma. Endocr Rev 43(6):1003–1037. 10.1210/endrev/bnac010 Moon JS, Shin SY (2020) Segmented retinal layer analysis of chiasmal compressive optic neuropathy in pituitary adenoma patients. Graefes Arch Clin Exp Ophthalmol 258(2):419–425. 10.1007/s00417-019-04560-3 Gnanalingham KK, Bhattacharjee S, Pennington R, Ng J, Mendoza N (2005) The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry 76(3):415–419. 10.1136/jnnp.2004.035576 Muskens IS, Zamanipoor Najafabadi AH, Briceno V et al (2017) Visual outcomes after endoscopic endonasal pituitary adenoma resection: a systematic review and meta-analysis. Pituitary 20(5):539–552. 10.1007/s11102-017-0815-9 Uy B, Wilson B, Kim WJ, Prashant G, Bergsneider M (2019) Visual Outcomes After Pituitary Surgery. Neurosurg Clin N Am 30(4):483–489. 10.1016/j.nec.2019.06.002 Danesh-Meyer HV, Yoon JJ, Lawlor M, Savino PJ (2019) Visual loss and recovery in chiasmal compression. Prog Retin Eye Res 73:100765. 10.1016/j.preteyeres.2019.06.001 Shin HY, Park HYL, Jung KI, Park CK (2013) Comparative Study of Macular Ganglion Cell–Inner Plexiform Layer and Peripapillary Retinal Nerve Fiber Layer Measurement: Structure–Function Analysis. Investig Ophthalmol Vis Sci 54(12):7344–7353. 10.1167/iovs.13-12667 Cennamo G, Auriemma RS, Cardone D et al (2015) Evaluation of the retinal nerve fibre layer and ganglion cell complex thickness in pituitary macroadenomas without optic chiasmal compression. Eye 29(6):797–802. 10.1038/eye.2015.35 Blanch RJ, Micieli JA, Oyesiku NM, Newman NJ, Biousse V (2018) Optical coherence tomography retinal ganglion cell complex analysis for the detection of early chiasmal compression. Pituitary 21(5):515–523. 10.1007/s11102-018-0906-2 Tieger MG, Hedges TR, Ho J et al (2017) Ganglion Cell Complex Loss in Chiasmal Compression by Brain Tumors. J Neuroophthalmol 37(1):7–12. 10.1097/WNO.0000000000000424 Moon CH, Hwang SC, Ohn YH, Park TK (2011) The Time Course of Visual Field Recovery and Changes of Retinal Ganglion Cells after Optic Chiasmal Decompression. Investig Ophthalmol Vis Sci 52(11):7966–7973. 10.1167/iovs.11-7450 Yoo YJ, Hwang JM, Yang HK, Joo JD, Kim YH, Kim CY (2020) Prognostic value of macular ganglion cell layer thickness for visual outcome in parasellar tumors. J Neurol Sci 414:116823. 10.1016/j.jns.2020.116823 Hisanaga S, Kakeda S, Yamamoto J et al (2017) Pituitary Macroadenoma and Visual Impairment: Postoperative Outcome Prediction with Contrast-Enhanced FIESTA. Am J Neuroradiol 38(11):2067–2072. 10.3174/ajnr.A5394 Zhang Y, Chen C, Huang W et al (2023) Preoperative volume of the optic chiasm is an easily obtained predictor for visual recovery of pituitary adenoma patients following endoscopic endonasal transsphenoidal surgery: a cohort study. Int J Surg 109(4):896. 10.1097/JS9.0000000000000357 Luomaranta T, Raappana A, Saarela V, Liinamaa MJ (2017) Factors Affecting the Visual Outcome of Pituitary Adenoma Patients Treated with Endoscopic Transsphenoidal Surgery. World Neurosurg 105:422–431. 10.1016/j.wneu.2017.05.144 Glebauskiene B, Liutkeviciene R, Zlatkute E, Kriauciuniene L, Zaliuniene D (2018) Association of retinal nerve fibre layer thickness with quantitative magnetic resonance imaging data of the optic chiasm in pituitary adenoma patients. J Clin Neurosci 50:1–6. 10.1016/j.jocn.2018.01.005 Menon S, Nair S, Kodnani A, Hegde A, Nayak R, Menon G (2023) Retinal nerve fiber layer thickness and its correlation with visual symptoms and radiological features in pituitary macroadenoma. J Neurosci Rural Pract 14(1):41–47. 10.25259/JNRP_18_2022 Otsu N (1979) A Threshold Selection Method from Gray-Level Histograms. IEEE Trans Syst Man Cybernetics 9(1):62–66. 10.1109/TSMC.1979.4310076 DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44(3):837–845 Youden WJ (1950) Index for rating diagnostic tests. Cancer 3(1):32–35. 10.1002/1097-0142(1950)3:13.0.co;2-3 Danesh-Meyer HV, Wong A, Papchenko T et al (2015) Optical coherence tomography predicts visual outcome for pituitary tumors. J Clin Neurosci 22(7):1098–1104. 10.1016/j.jocn.2015.02.001 Jacob M, Raverot G, Jouanneau E et al (2009) Predicting Visual Outcome After Treatment of Pituitary Adenomas With Optical Coherence Tomography. Am J Ophthalmol 147(1):64–70e2. 10.1016/j.ajo.2008.07.016 Han KE, Choi H, Kim SJ, Lee SM, Lee JE (2024) Clinical efficacy of optical coherence tomography parameters to predict the visual field outcome following pituitary adenoma surgery. PLoS ONE 19(11):e0313521. 10.1371/journal.pone.0313521 Lee GI, Park KA, Lee D, Oh SY, Kong DS, Hong SD (2023) Predicting visual outcomes after decompression of pituitary tumours based on stratified inner-retinal layer thickness and age. Acta Ophthalmol 101(3):301–309. 10.1111/aos.15281 Xia L, Wenhui J, Xiaowen Y et al (2022) Predictive value of macular ganglion cell-inner plexiform layer thickness in visual field defect of pituitary adenoma patients: a case-control study. Pituitary 25(4):667–672. 10.1007/s11102-022-01248-6 Agarwal R, Jain VK, Singh S et al (2021) Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study. Indian J Ophthalmol 69(9):2378–2384. 10.4103/ijo.IJO_2086_20 Uvelius E, Valdemarsson S, Bengzon J, Hammar B, Siesjö P (2023) Visual acuity in patients with non-functioning pituitary adenoma: Prognostic factors and long-term outcome after surgery. Brain Spine 3:102667. 10.1016/j.bas.2023.102667 Li P, Zhang D, Ma S et al (2021) Consistency of pituitary adenomas: Amounts of collagen types I and III and the predictive value of T2WI MRI. Exp Ther Med 22(5):1255. 10.3892/etm.2021.10690 Esposito D, Olsson DS, Ragnarsson O, Buchfelder M, Skoglund T, Johannsson G (2019) Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management. Pituitary 22(4):422–434. 10.1007/s11102-019-00960-0 Molitch ME (2017) Diagnosis and Treatment of Pituitary Adenomas: A Review. JAMA 317(5):516–524. 10.1001/jama.2016.19699 Abdulbaki A, Kanaan I (2017) The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration. Surg Neurol Int 8:16. 10.4103/2152-7806.199557 Sahyouni R, Goshtasbi K, Choi E et al (2019) Vision Outcomes in Early versus Late Surgical Intervention of Pituitary Apoplexy: Meta-Analysis. World Neurosurg 127:52–57. 10.1016/j.wneu.2019.03.133 Sathe AV, Siu A, Kang KC et al (2023) Early Versus Delayed Fractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. World Neurosurg 180:e317–e323. 10.1016/j.wneu.2023.09.067 Pomeraniec IJ, Kano H, Xu Z et al (2018) Early versus late Gamma Knife radiosurgery following transsphenoidal surgery for nonfunctioning pituitary macroadenomas: a multicenter matched-cohort study. J Neurosurg 129(3):648–657. 10.3171/2017.5.JNS163069 Pomeraniec IJ, Dallapiazza RF, Xu Z, Jane JA, Sheehan JP (2016) Early versus late Gamma Knife radiosurgery following transsphenoidal resection for nonfunctioning pituitary macroadenomas: a matched cohort study. J Neurosurg 125(1):202–212. 10.3171/2015.5.JNS15581 Tables Clinical Characteristics (n=68) Age 53.3 Female 30 Follow-up duration (weeks) 97.0 VA (logMAR) -Right eye -Left eye -Worse eye 0.20 0.36 0.43 VF MD (dB) -Right eye -Left eye -Worse eye -6.61 -7.59 -8.80 RNFL thickness (µm) -Right eye -Left eye -Worse eye 86.4 83.7 81.9 Overall GCC thickness (µm) -Right eye -Left eye -Worse eye 72.0 71.3 69.1 Nasal GCC thickness (µm) -Right eye -Left eye -Worse eye 69.2 69.3 67.1 Temporal GCC thickness (µm) -Right eye -Left eye -Worse eye 75.1 73.5 70.8 MRI (n=36) Tumour volume (cm 3 ) 11.5 Tumour Diameter in the largest dimension (cm) 3.0 Chiasmal involvement -Approaches but not contacting -Abutment -Displacement/compression 2 9 23 Optic nerve involvement -Approaches but not contacting -Abutment -Displacement/compression Right eye 9 7 20 Left eye 9 5 22 Extension into cavernous sinus -Yes -No Right eye 12 24 Left eye 19 17 Preop Visual Field Defect None/normal Temporal loss Central loss Diffuse loss Nasal loss 24 49 2 12 1 Postop Residual Tumour None Trace Gross 5 22 7 Table 1. Clinical and MRI characteristics of patients identified with pituitary macroadenomas approaching or contacting the chiasm. Characteristic Final VA 20/40 or better Final VA 20/50 or worse P value Age at surgery (years) 52.9 54.1 .8 Preop VA (logMAR) 0.3 1.3 .02* Preop VF (dB) -8.1 -17.9 .03* Preop RNFL (µm) 81.9 69.5 .01* Preop GCC (µm) Total Nasal sectors Temporal sectors 69.0 64.6 73.4 50.5 49.3 52.5 <.001* .01* <.001* Tumour Volume (cm 3 ) 9.4 18.7 .054 Tumour diameter in the largest dimension (cm) 2.8 3.5 .07 Optic Nerve Appearance Normal Temporal pallor Diffuse pallor 46 24 6 3 3 4 .2 .99 .012 † Chiasm Involvement No contact Abutment Displacement/compression 2 9 15 0 0 8 .08 Optic Nerve Involvement No contact Abutment Displacement/Compression 16 11 33 2 1 5 .9 Extension into Cavernous Sinus Yes No 24 36 4 4 .7 Preop Visual Field Defect None/normal Temporal loss Central loss Diffuse loss Nasal loss 22 46 2 5 1 2 3 0 7 0 .99 .6 .99 .013 † .99 Postop Residual Tumour None Trace Gross 3 18 5 2 4 2 .548 Characteristic Final VF -5dB or better Final VF worse than -5dB P value Age at surgery (years) 49.1 60.3 .017* Preop VA (logMAR) 0.3 0.7 .05* Preop VF (dB) -7.4 -14.5 <.001* Preop RNFL (µm) 84.1 70.5 <.001* Preop GCA (µm) Total Nasal sectors Temporal sectors 71.2 66.5 75.9 55.6 52.4 59.4 <.001* <.001* <.001* Tumour Volume (cm 3 ) 8.4 18.2 .024* Tumour diameter in the largest dimension (cm) 2.8 3.4 .1 Optic Nerve Appearance Normal Temporal pallor Diffuse pallor 37 18 4 8 9 6 .07 .8 .056 Chiasm Involvement No contact Abutment Displacement/Compression 1 7 15 1 2 8 .7 Optic Nerve Involvement No contact Abutment Displacement/Compression 10 9 28 7 1 9 .2 Extension into Cavernous Sinus Yes No 20 27 8 9 .8 Preop Visual Field Defect None/normal Temporal loss Central loss Diffuse loss Nasal loss 19 37 0 5 0 3 10 2 7 1 .6 .7 .2 .2 .6 Postop Residual Tumour None Trace Gross 2 16 5 3 6 2 .08 *Significant at p<0.05 † Not significant after Bonferroni correction. Table 2. Clinical and MRI factors associated with visual prognosis in patients who underwent transsphenoidal resection of pituitary macroadenomas. Characteristic Surgery within 1 year (n=38) Surgery after 1 year or observed for 1 year (n=30) P value Presenting VA (logMAR) 0.16 0.65 .001 Presenting VF MD (dB) -3.97 -12.6 <.001 RNFL thickness (µm) 88.7 76.5 . 005 GCC thickness (µm) -Overall -Nasal -Temporal 74.3 74.8 73.1 64.6 60.5 68.9 .17 <.001 .314 Tumour volume (cm 3 ) 5.3 13.0 .120 Table 3: Clinical and MRI factors between those who underwent transsphenoidal resection of pituitary macroadenomas within 1 year versus those who did not. Clinical characteristics were obtained from the worse seeing eye in each patient. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7521873","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512099259,"identity":"bf122ac1-cd4a-47e3-bf97-3efdef17a86e","order_by":0,"name":"Marko (Chi-Wei) Tien","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Marko","middleName":"(Chi-Wei)","lastName":"Tien","suffix":""},{"id":512099260,"identity":"24808075-10bb-4cad-bda8-c0aedba90a6b","order_by":1,"name":"Lauren Pickel","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Pickel","suffix":""},{"id":512099261,"identity":"617cee61-e164-4886-a9fb-f499246335a2","order_by":2,"name":"Alexandre Boutet","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"","lastName":"Boutet","suffix":""},{"id":512099262,"identity":"dc1bdf0c-3388-45c7-84b8-b8b82f0beca3","order_by":3,"name":"Yash Patel","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Yash","middleName":"","lastName":"Patel","suffix":""},{"id":512099263,"identity":"d3360dcf-a4ab-454e-863e-efc03778375c","order_by":4,"name":"Mikail Malik","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Mikail","middleName":"","lastName":"Malik","suffix":""},{"id":512099264,"identity":"0d1845da-c565-4e74-a13c-a6229b3d9568","order_by":5,"name":"Ruth Lau","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Lau","suffix":""},{"id":512099265,"identity":"28c2fd99-6842-4432-b01d-8dacd760bbda","order_by":6,"name":"Aristotelis Kalyvas","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Aristotelis","middleName":"","lastName":"Kalyvas","suffix":""},{"id":512099266,"identity":"53f2cba8-4640-4e48-8791-e4f4b30eb453","order_by":7,"name":"Edward Margolin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYFCCBDApw8bAfABIS8gQrYWHjYENxJLgIV4LEBlAGQQAP3t24ueKXzY8fNI9n1/dqLHgYWA/fHQDPi2SPW83S57tS+Nhkzm7zTrnGNBhPGlpN/BpMbiRu0GysecwD5tE7jbjHDagFgkeM7xa7G/kbv4J0ZLzzDjnHxFaDICGSzb8AGthfpzbRoQWiTNvt1k2NgD9IpFmxpzbJ8HDRsgv/O25m282/LGRk5+R/Phzzrc6OX72w8fwagEDxjYwxSYBJgkqB4M/YJL5A3GqR8EoGAWjYKQBAAHgRKVqLLchAAAAAElFTkSuQmCC","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Edward","middleName":"","lastName":"Margolin","suffix":""}],"badges":[],"createdAt":"2025-09-03 02:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7521873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7521873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90929604,"identity":"b84f7c4d-ef60-4fbb-ad08-323958d7422f","added_by":"auto","created_at":"2025-09-09 16:05:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205367,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative MRI used to segment pituitary adenoma. (A) T2-weighted MRI sella with manually segmented adenoma (B, in red) showing coronal (main), sagittal (right), and axial (bottom) views. (C) Post-contrast whole brain MRI with manually segmented adenoma (D, in red), showing coronal (top left), sagittal (top right), and axial (bottom left) views.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7521873/v1/6c4aea1c2932857436b45864.jpeg"},{"id":90929608,"identity":"3c4050a6-9622-4fdd-aec9-7f5ff2cf2085","added_by":"auto","created_at":"2025-09-09 16:05:34","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":156936,"visible":true,"origin":"","legend":"\u003cp\u003ePoint biserial correlations between retinal nerve fiber layer (top) and ganglion cell complex thicknesses (bottom) with recovery of visual acuity to 20/40 and recovery of visual field mean deviation to -5dB or better. RNFL = retinal nerve fiber layer, GCC = ganglion cell complex.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7521873/v1/7af0317a5d3be8953a077608.jpeg"},{"id":90929606,"identity":"24debd28-9a03-4de6-b982-0fa5dc2d0fda","added_by":"auto","created_at":"2025-09-09 16:05:33","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87728,"visible":true,"origin":"","legend":"\u003cp\u003ePoint biserial correlations between tumor volume with recovery of visual acuity to 20/40 and recovery of visual field mean deviation to -5dB or better. Tumor volume was significantly associated with recovery of visual field only. RNFL = retinal nerve fiber layer, GCC = ganglion cell complex.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7521873/v1/b77acedeeba1052b082fa545.jpeg"},{"id":90931614,"identity":"4629c311-39e4-4087-8640-974bb00fd9f0","added_by":"auto","created_at":"2025-09-09 16:21:34","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":171674,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver-Operating Characteristic (ROC) curves from preoperative RNFL/GCC and visual outcomes. A) ROC curve predicting final VA 20/40 or better using preoperative RNFL thickness. Area under curve (AUC)=0.73. B) ROC curve predicting final VA 20/40 or better using preoperative GCC thickness. AUC=0.86 (overall), 0.81 (nasal GCC), 0.86 (temporal GCC). C) ROC curve predicting final VF -5dB or better using preoperative RNFL thickness. AUC=0.81. D) ROC curve predicting final VF -5dB or better using preoperative GCC thickness. AUC=0.85 (overall), 0.81 (nasal GCC), 0.84 (temporal GCC).\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7521873/v1/76d1e47d93854a8183b8bfb6.jpeg"},{"id":96239177,"identity":"eb70ecd6-b181-47dc-abeb-30ed76e865ca","added_by":"auto","created_at":"2025-11-19 07:04:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1299536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7521873/v1/8765dd88-8488-4cd8-9459-c80f764358e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of visual outcomes in urgent or delayed pituitary macroadenoma resection","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePituitary adenomas are among the most common intracranial neoplasms, comprising a diverse group of tumours arising from the pituitary gland.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Although typically benign,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e they can cause significant morbidity through hormonal hypersecretion or local invasion.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Vision loss is a common presenting feature and occurs through two main processes. Blockage of signal conduction at the optic chiasm can cause rapid but potentially reversible vision loss. Secondly, physical compression of the optic apparatus disrupts axo-plasmic flow via anterograde and retrograde degeneration of retinal ganglion cells with potentially irreversible blindness.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Optical coherence tomography (OCT) is a non-invasive, non-ionizing imaging modality readily available in most ophthalmic practices that can visualize retrograde degeneration as thinning of the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC).\u003c/p\u003e\u003cp\u003eThe visual pathway can be decompressed through surgical resection of the tumor, but recovery of vision is variable and complicates the decision to undergo surgery in asymptomatic patients.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Several factors have been proposed to influence visual outcomes including age, severity of preoperative visual deficit, tumour size, RNFL thickness, and GCC thickness, which may be the most sensitive predictor.\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e GCC loss directly corresponds to axonal damage, and greater preoperative GCC thickness has been correlated with postoperative visual field (VF) improvement.\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMagnetic resonance imaging (MRI) is a key tool for surgical planning. Preoperative tumour volume may predict final visual outcomes,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e but other findings such as volume of the optic chiasm and extent of suprasellar invasion have been associated with visual recovery.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e To our knowledge, few studies have directly compared the relative prognostic value of OCT and MRI features of pituitary adenomas to predict postoperative visual recovery. Several studies have demonstrated an association between thinner preoperative RNFL measurements with greater suprasellar extension and optic chiasm compression.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e No studies have otherwise correlated MRI characteristics with ganglion cell analysis and investigated whether MRI or OCT findings more strongly predict visual outcomes.\u003c/p\u003e\u003cp\u003eThus, our study sought to correlate MRI and OCT measurements with vision outcomes in patients with pituitary adenomas post-transsphenoidal resection. We also sought to identify clinical and imaging factors in patients who deferred operative management by one year and characterize their visual outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective cohort study was conducted by the Departments of Neurosurgery, Medical Imaging, and Ophthalmology \u0026amp; Vision Sciences with approval from the University of Toronto Research Ethics Board and adhered to the Declaration of Helsinki. Informed consent was waived given the retrospective nature of the study. Patients from a single tertiary neuro-ophthalmology clinic diagnosed with non-functioning pituitary macroadenoma through clinical presentation, hormonal profile, and radiologic investigations were identified between January 1, 2008, and September 30, 2024. Inclusion criteria were non-secretory tumors approaching or contacting the optic chiasm as evidenced on dedicated MRI of the sella. Exclusion criteria included a history of previous pituitary surgery/radiotherapy or confounding ophthalmic disease affecting the optic nerve or retina apart from compressive optic neuropathy.\u003c/p\u003e\u003cp\u003eDemographic data collected included age and gender. Clinical measures included best-corrected visual acuity (VA), VF mean deviation (MD) measured by Humphrey 24\u0026thinsp;\u0026minus;\u0026thinsp;2 perimetry, and the appearance of the optic nerve on fundoscopy (normal, temporal pallor, diffuse pallor, edema). Spectral-domain OCT was performed to measure the average thicknesses of the RNFL and of the nasal, temporal and overall GCC. All clinical measures were collected at initial presentation and 6 months postoperatively or sooner if no later follow-up was available following surgery, or at the 1-year follow-up appointment if no surgery was pursued. Positive VA outcome was defined as a final VA of 20/40 or greater. Positive VF outcome was defined as a final VF MD of -5dB or better. Measurements were taken from both eyes in all patients when appropriate.\u003c/p\u003e\u003cp\u003eMRI sella (voxel size: 0.5 x 0.5 x 2mm) or brain MRI (voxel size: 1 x 1 x 1mm) were acquired within 6 months preoperatively and at 1 year postoperatively or sooner. Using preoperative contrast images when available, otherwise T2-weighted images, a semi-automated method was used for tumor segmentation to obtain their preoperative volume (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.slicer.org/\u003c/span\u003e\u003cspan address=\"https://www.slicer.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e): first the Otsu threshold was applied to isolate tumor regions by creating an optimal binary thresholded image that separates an image into foreground and background components,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e then the grow from seeds module was used to generate a 3D segmentation, which was manually adjusted in all planes by LP and then verified for accuracy by AB (board certified neuroradiologist) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition to volume, maximum anteroposterior, craniocaudal, and transverse dimensions of tumors were measured from coronal or sagittal sections. Postoperative tumor residual was defined as none (nonvisible), minimal (millimetric soft tissue), and gross residual (nodular obvious residual) on postoperative MRI scans. Semi-quantitative visual assessments of relationships with optic apparatus and the cavernous sinuses were performed for the pre- and postoperative MRI. For optic nerves (right and left) and chiasms, the mass was considered to be separate from, abutting, or displacing them. Cavernous sinus invasion was defined as a Knosp classification of grade 3 or greater. Similar to tumor segmentations, these were generated by LP and verified for accuracy by AB (board certified neuroradiologist).\u003c/p\u003e\u003cp\u003eDescriptive and inferential statistics were conducted using IBM SPSS Statistics (ver. 29.0.1.0). Continuous variables were reported as mean values with a range and standard deviation (SD). Analysis of variance (ANOVA) was conducted to assess for relationships between continuous data and VA/VF outcome. Chi-Square with Bonferroni correction was performed to identify associations between categorical variables. Pearson\u0026rsquo;s coefficient (\u003cem\u003er\u003c/em\u003e) and point biserial correlations were calculated to characterize correlations between study variables and VA/VF outcome, and Fisher\u0026rsquo;s z-transformation was used to identify significant differences in correlation coefficients. Receiver-Operating Characteristic (ROC) curve analysis was conducted to assess the utility of preoperative RNFL/GCC thickness in predicting VA and VF MD outcomes. The areas under the curve (AUCs) were calculated and compared using the methods described by Delong et al.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Cutoff points maximizing the sensitivity and specificity were identified using the Youden Index (\u003cem\u003eJ\u003c/em\u003e).\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e All figures were created in IBM SPSS Statistics and edited in GIMP.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e68 patients were included in the study. 38 underwent surgery within a year of presentation, while 30 either did not have surgery after one year of follow-up or had surgery after at least one year. At the time of data collection, a total of 44 patients had undergone transsphenoidal resection. Of the entire cohort, 30 patients were female, and the mean age was 53.3 years (SD 1.89, range 20 to 85). Average follow-up interval was 97.0 weeks (SD 8.8, range 8.0 to 344.6). Further baseline clinical characteristics are outlined in Table 1.\u003c/p\u003e\n\u003cp\u003eOf the 44 patients who underwent surgery, 36 had preoperative and 34 had postoperative MRI available to review (Table 2). Eyes achieving a positive VA outcome demonstrated better preoperative VA (0.3 vs 1.3, \u003cem\u003eP\u003c/em\u003e=.02), VF MD (-8.1dB vs -17.9dB, \u003cem\u003eP\u003c/em\u003e=.03), thicker RNFL (81.9\u0026micro;m vs 69.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e=.01) and thicker overall GCC (69.0\u0026micro;m vs 50.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001), nasal GCC (64.6\u0026micro;m vs 49.3\u0026micro;m, \u003cem\u003eP\u003c/em\u003e=.01), and temporal GCC (73.4\u0026micro;m vs 52.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) sectors than eyes achieving a poor VA outcome. Eyes achieving a positive VF outcome also demonstrated better preoperative VA (0.3 vs 0.7, \u003cem\u003eP\u003c/em\u003e=.05), VF MD (-7.4dB vs -14.5dB, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001), thicker RNFL (85.1\u0026micro;m vs 70.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) and thicker overall (71.2\u0026micro;m vs 55.6\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001), nasal (66.5\u0026micro;m vs 52.4\u0026micro;m, p\u0026lt;0.001), and temporal GCC (75.9\u0026micro;m vs 59.4\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) sectors than eyes with a poor VF outcome. Smaller tumor volume (8.4cm\u003csup\u003e3\u003c/sup\u003e vs 18.2cm\u003csup\u003e3\u003c/sup\u003e, \u003cem\u003eP\u003c/em\u003e=.024) and younger age at surgery (49.1 years vs 60.3 years, \u003cem\u003ep\u003c/em\u003e=.017) were also associated with positive VF outcomes. The rest of the MRI characteristics investigated including optic nerve/chiasm involvement, residual tumor volume, maximal dimension of the tumour, and invasion into the cavernous sinus were not significantly associated with visual outcomes.\u003c/p\u003e\n\u003cp\u003eBoth RNFL and GCC thickness correlated with positive VA (\u003cem\u003er\u003c/em\u003e=0.28 (95% CI [0.068, 0.47]) \u003cem\u003eP\u003c/em\u003e=.01; 0.41 (95% CI [0.18, 0.60]) \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) and positive VF outcomes (\u003cem\u003er\u003c/em\u003e=0.44 (95% CI [0.24, 0.60]) \u003cem\u003eP\u003c/em\u003e\u0026lt;.001; 0.57 (95% CI [0.37, 0.72]), \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) (Figure 2); however, equivalence testing did not reveal a significant difference between RNFL and GCC correlation coefficients (\u003cem\u003eP\u003c/em\u003e=.4 and .3 for VA and VF respectively). Tumor volume significantly correlated with positive VF outcome (\u003cem\u003er\u003c/em\u003e=-0.39 (95% CI [-0.64, -0.056]), \u003cem\u003eP\u003c/em\u003e=.024) but not with positive VA outcome (\u003cem\u003er\u003c/em\u003e=-0.33 (95% CI [-0.60, 0.0058]), \u003cem\u003eP\u003c/em\u003e=.054) (Figure 3). Tumor volume also correlated with RNFL thickness (\u003cem\u003er=\u003c/em\u003e-0.45 (95% CI [-0.69, -0.11]), \u003cem\u003eP=\u003c/em\u003e.011) and GCC thickness (\u003cem\u003er=\u003c/em\u003e-0.46 (95% CI [-0.73, -0.067]), \u003cem\u003eP=\u003c/em\u003e.024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROC curves for RNFL/GCC thickness predicting VA/VF outcomes are shown in Figure 4. All AUCs ranged between 0.8 and 0.86, except for the ROC curve of preoperative RNFL thickness predicting VA outcome with an AUC of 0.73. Differences between AUCs were not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026rsquo;s\u0026gt;0.1). Cutoff points of preoperative RNFL thickness was 73.5\u0026micro;m (\u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.46) for predicting positive VA outcome and 77.0\u0026micro;m (\u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.58) for predicting positive VF outcome. Cutoff points of preoperative GCC thickness were 56.5\u0026micro;m (overall, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.71), 56.3\u0026micro;m (nasal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.47) and 64.5\u0026micro;m (temporal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.68)\u0026nbsp;for predicting positive VA outcome and was 59.5\u0026micro;m (overall, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.51), 51.5\u0026micro;m (nasal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.46) and 66.8 (temporal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.51)\u0026nbsp;for predicting positive VF MD outcome.\u003c/p\u003e\n\u003cp\u003eAmong 22 patients with a preoperative VA of 20/50 or worse, preoperative RNFL thickness (\u003cem\u003er\u003c/em\u003e=0.63 (95% CI [0.28, 0.83])) and preoperative GCC thickness (overall (\u003cem\u003er\u003c/em\u003e=0.63 (95% CI [0.16, 0.87])), nasal (\u003cem\u003er\u003c/em\u003e=0.55 (95% CI [0.023, 0.84])), and temporal (\u003cem\u003er\u003c/em\u003e=0.69 (95% CI [0.25, 0.89]))) were correlated with an improvement in VA to 20/40 or better after surgery. Cutoff points predicting improvement to 20/40 or better were 60.0\u0026micro;m (\u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=1.0) for preoperative RNFL thickness 53.0\u0026micro;m (overall, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.92), 51.5\u0026micro;m (nasal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.83) and 54.8.5\u0026micro;m (temporal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.92) for preoperative GCC thickness. Among 35 patients with a preoperative VF of -5dB or worse, preoperative RNFL thickness (\u003cem\u003er\u003c/em\u003e=0.52 (95% CI [0.21, 0.73])) and preoperative GCC thickness (overall (\u003cem\u003er\u003c/em\u003e=0.73 (95% CI [0.45, 0.88])), nasal (\u003cem\u003er\u003c/em\u003e=0.64 (95% CI [0.30, 0.84])), and temporal (\u003cem\u003er\u003c/em\u003e=0.74 (95% CI [0.47, 0.89]))) were correlated with an improvement in postoperative VF to -5dB or better. RNFL and GCC (overall, nasal, temporal) thickness cutoff points predicting return of VF to -5dB or better were 67.5\u0026micro;m (\u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.57) and 61.0\u0026micro;m (overall, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=1.0), 50.8\u0026micro;m (nasal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=0.86) and 69.8\u0026micro;m (temporal, \u003cem\u003eJ\u003c/em\u003e\u003csub\u003emax\u003c/sub\u003e=1.0), respectively. Multiple regression analyses did not identify a factor most predictive of VA or VF recovery in patients with an already poor preoperative VA or VF.\u003c/p\u003e\n\u003cp\u003eOf the 30 patients who had surgery deferred, observation was recommended as the tumor was abutting the chiasm but not producing visual deficits in 15 and was approaching but not contacting the chiasm in 11. 2 patients requested observation, one experienced delay in seeing the neurosurgical team, and one could not undergo surgery due to medical instability. In all patients who had surgery deferred, a joint decision was made between the patient, neurosurgical, and neuro-ophthalmologic teams to maintain close follow-up with serial MRIs, VF/OCT imaging, and visual assessments in accordance with local practice guidelines. There was no significant difference in the proportion of patients who recovered VA to 20/40 (\u003cem\u003eP\u003c/em\u003e=.69) or VF to -5dB or better (\u003cem\u003eP\u003c/em\u003e=.10) in the worse-seeing eye between patients who had surgery within one year and those who did not. Those who had surgery deferred, in the worse-seeing eye, had better presenting VA (0.16 vs 0.65, \u003cem\u003eP\u003c/em\u003e=.001), VF MD (-3.97dB vs -12.61dB, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001), thicker RNFL (88.7\u0026micro;m vs 76.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e=.005), thicker overall (74.3\u0026micro;m vs 64.6\u0026micro;m, \u003cem\u003eP\u003c/em\u003e=.017) and nasal GCC sectors (74.7\u0026micro;m vs 60.5\u0026micro;m, \u003cem\u003eP\u003c/em\u003e\u0026lt;.001) than those who had surgery within one year (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the clinical and MRI parameters associated with visual outcomes following early or delayed resection of pituitary macroadenomas approaching or contacting the chiasm. Similar to previous studies, preoperative VA, VF MD, RNFL/GCC thickness and tumor volume were associated with positive VA and VF outcomes. Even in those with poor preoperative vision, RNFL and GCC thickness are correlated with visual recovery. Furthermore, patients who had surgery deferred by a year were closely followed by both neurosurgical and neuro-ophthalmologic teams and had similar visual outcomes as those who received surgery within 1 year of presentation.\u003c/p\u003e\u003cp\u003eOnce chiasmal compression from pituitary macroadenomas induces nerve atrophy, vision loss may be permanent. For this reason, RNFL thinning is strongly prognostic of poor visual recovery. Several studies have previously demonstrated the relationship between RNFL thickness and post-surgical visual recovery.\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Ganglion cell inner plexiform layer thickness has also recently gained interest as a predictor of visual recovery, though results are mixed.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Few if any large-scale studies have directly compared the prognostic value between RNFL and GCC thickness in patients with pituitary macroadenomas. Our findings are in line with previous work which has demonstrated poor visual outcomes in patients with thinner preoperative RNFL and GCC thicknesses. Furthermore, our equivalence testing showed that the relative strength of the correlation between visual outcomes and RNFL versus GCC thicknesses are similar (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and ROC analysis identified cutoff points of preoperative RNFL and GCC thicknesses in predicting VA/VF outcomes, suggesting that either may be used as a prognostic marker. Though OCT imaging is commonplace in most ophthalmology clinics, ganglion cell analysis software may not be readily available, especially in low-income countries where the costs of an OCT machine with advanced software may be inaccessible. Therefore, basic RNFL analysis may provide similar prognostic capabilities to GCC analysis in predicting visual outcomes after surgical decompression of pituitary macroadenomas.\u003c/p\u003e\u003cp\u003eRNFL thickness and tumour volume were correlated with one another as seen in previous studies.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Additionally, we show that GCC thickness is also correlated with tumour volume. Compression of the visual apparatus induces retrograde degeneration of retinal ganglion cells which becomes apparent as thinning of the macular GCC and peripapillary RNFL. While some preliminary studies have demonstrated higher sensitivity of GCC thinning in detecting chiasmal compression over RNFL thinning, future studies may further investigate whether chiasmal compression is detected earlier on GCC or RNFL analysis.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCertain MRI findings such as pituitary tumour size, degree of suprasellar extension, and volume of the optic chiasm have been reported as prognosticators of visual recovery.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e We demonstrated a correlation between tumour volume and positive VF outcome, but not with positive VA outcomes. One explanation for this finding is that the shape of the tumour may affect VA more than its absolute volume. One study demonstrated that the tumour height above the sella may influence VA recovery more than overall tumour volume.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Furthermore, the soft consistency of pituitary adenomas may not exert sufficient compressive forces on the macular fibers to cause dysfunction depending on the tumour\u0026rsquo;s shape.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e We were also unable to find an association between perceived chiasm/optic nerve compression and visual outcomes. Therefore, sole visual interpretation of pituitary adenomas, especially those which are atypically shaped, may be a limited predictor of visual outcome unless there is marked compression or apoplexy.\u003c/p\u003e\u003cp\u003eSurgery is often indicated when hormonal or visual deficits are present; however, asymptomatic large growing tumors may also be operated on to prevent future blindness.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Surgery itself can induce hormonal derangements and vision loss through damage to nearby structures; thus, the decision to operate must be balanced by the potential harms and benefits.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Though no studies to our knowledge have previously investigated the visual outcomes of early versus late pituitary decompression, several have demonstrated similar visual outcomes following early versus late surgical management of pituitary apoplexy.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e The role of early versus late radiotherapy for adjuvant treatment has also been explored, with one study demonstrating no significant differences in development of endocrinopathies or permanent visual deficits between patients who received early or delayed adjuvant radiotherapy.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Others have shown that early adjuvant radiotherapy within 6 months of resection reduced tumour recurrence rates and decreased the risk of developing endocrinopathies; however, visual outcomes were not evaluated.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e The decision to defer surgery is dependent on the degree of preoperative visual compromise and structural damage to the optic apparatus; however, other factors such as tumor progression, surgical complexity, and endocrine dysfunction may warrant more urgent management despite favourable preoperative visual parameters. In our study, the decision to observe or pursue surgery was based on multiple factors including but not limited to tumor size and its spatial relation with the optic chiasm, presence of visual deficits and optic atrophy, tumor growth rate, and the medical status and wishes of the patient. Those who were not immediately scheduled for transsphenoidal resection were closely monitored by both neurosurgical and neuro-ophthalmologic teams, and the decision to undergo surgery was revisited at each follow-up. Of those who happened to have surgery deferred by at least a year, we found no significant differences in visual outcomes compared to patients who received primary surgical resection of non-functioning pituitary macroadenomas within one year of presentation. Further prospective studies with larger cohorts are required to determine whether deferring surgical resection of pituitary adenomas can be advisable in certain cases.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThere were several limitations to our study. Firstly, MRI was not available to review for all patients. Secondly, many of our MRI parameters were obtained using semi-quantitative measures to replicate standard-of-care neuroradiology interpretations. This may have limited our ability to draw statistical associations, for example between visual outcomes and the relationship of the pituitary macroadenoma with the optic chiasm. Finally, we did not specifically investigate postoperative visual decline and the intraoperative factors that may influence vision loss after transsphenoidal resection as we did not have access to operative reports for all patients, nor did we have enough patients who experienced visual decline greater than 2 Snellen lines or worsening of VF MD by at least 2dB. We also wish to stress the importance of considering clinical, radiologic, and hormonal factors when deciding which patients require urgent pituitary decompression and which patients can be observed. In all cases, patients should be closely monitored by neurosurgical and neuro-ophthalmologic teams and the decision to pursue surgery should be revisited at each follow-up considering changes to the patient\u0026rsquo;s status or tumor characteristics. Future multi-center studies with larger, more heterogenous cohorts, and longer follow-up periods may offer further information to guide clinicians and surgeons in their discussions with patients on balancing the risks of vision loss from surgery versus from delaying treatment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, we demonstrated several predictors of VA and VF outcomes after transsphenoidal resection of pituitary macroadenomas, including age, preoperative VA/VF MD, RNFL/GCC thickness, and tumour volume. RNFL, GCC, and tumour volume were similarly powerful prognostic factors for the prediction of visual outcomes, though tumour volume was significantly associated only with VF and not VA outcomes. While it may be appropriate for some patients with favourable preoperative visual parameters to defer surgery, further prospective studies are needed to assess the safety and long-term effects of deferred surgery on tumor progression, surgical complexity, and endocrine function.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNone of the authors have any relevant conflicts of interest to disclose. \u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePreoperative VA/VF MD/RNFL/GCC thickness may predict visual outcomes after pituitary macroadenoma resection. Future studies are required to evaluate the safety of deferring surgery, even with favourable preoperative visual parameters.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.M., A.K., and A.B. conceptualized and oversaw the study. M.T., L.P., Y.P., M.M., R.L. collected patient data. M.T. and L.P. analyzed the study data. M.T. and L.P wrote the main manuscript text. M.T. created the tables and figures. All authors reviewed the manuscript prior to submission.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript and can be made available through the first author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eScheithauer BW, Gaffey TA, Lloyd RV et al (2006) Pathobiology of Pituitary Adenomas and Carcinomas. Neurosurgery 59(2):341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1227/01.NEU.0000223437.51435.6E\u003c/span\u003e\u003cspan address=\"10.1227/01.NEU.0000223437.51435.6E\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEzzat S, Asa SL, Couldwell WT et al (2004) The prevalence of pituitary adenomas. Cancer 101(3):613\u0026ndash;619. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.20412\u003c/span\u003e\u003cspan address=\"10.1002/cncr.20412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMelmed S, Kaiser UB, Lopes MB et al (2022) Clinical Biology of the Pituitary Adenoma. Endocr Rev 43(6):1003\u0026ndash;1037. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1210/endrev/bnac010\u003c/span\u003e\u003cspan address=\"10.1210/endrev/bnac010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoon JS, Shin SY (2020) Segmented retinal layer analysis of chiasmal compressive optic neuropathy in pituitary adenoma patients. Graefes Arch Clin Exp Ophthalmol 258(2):419\u0026ndash;425. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00417-019-04560-3\u003c/span\u003e\u003cspan address=\"10.1007/s00417-019-04560-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGnanalingham KK, Bhattacharjee S, Pennington R, Ng J, Mendoza N (2005) The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry 76(3):415\u0026ndash;419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/jnnp.2004.035576\u003c/span\u003e\u003cspan address=\"10.1136/jnnp.2004.035576\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuskens IS, Zamanipoor Najafabadi AH, Briceno V et al (2017) Visual outcomes after endoscopic endonasal pituitary adenoma resection: a systematic review and meta-analysis. Pituitary 20(5):539\u0026ndash;552. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11102-017-0815-9\u003c/span\u003e\u003cspan address=\"10.1007/s11102-017-0815-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUy B, Wilson B, Kim WJ, Prashant G, Bergsneider M (2019) Visual Outcomes After Pituitary Surgery. Neurosurg Clin N Am 30(4):483\u0026ndash;489. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nec.2019.06.002\u003c/span\u003e\u003cspan address=\"10.1016/j.nec.2019.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDanesh-Meyer HV, Yoon JJ, Lawlor M, Savino PJ (2019) Visual loss and recovery in chiasmal compression. Prog Retin Eye Res 73:100765. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.preteyeres.2019.06.001\u003c/span\u003e\u003cspan address=\"10.1016/j.preteyeres.2019.06.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShin HY, Park HYL, Jung KI, Park CK (2013) Comparative Study of Macular Ganglion Cell\u0026ndash;Inner Plexiform Layer and Peripapillary Retinal Nerve Fiber Layer Measurement: Structure\u0026ndash;Function Analysis. Investig Ophthalmol Vis Sci 54(12):7344\u0026ndash;7353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1167/iovs.13-12667\u003c/span\u003e\u003cspan address=\"10.1167/iovs.13-12667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCennamo G, Auriemma RS, Cardone D et al (2015) Evaluation of the retinal nerve fibre layer and ganglion cell complex thickness in pituitary macroadenomas without optic chiasmal compression. Eye 29(6):797\u0026ndash;802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/eye.2015.35\u003c/span\u003e\u003cspan address=\"10.1038/eye.2015.35\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlanch RJ, Micieli JA, Oyesiku NM, Newman NJ, Biousse V (2018) Optical coherence tomography retinal ganglion cell complex analysis for the detection of early chiasmal compression. Pituitary 21(5):515\u0026ndash;523. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11102-018-0906-2\u003c/span\u003e\u003cspan address=\"10.1007/s11102-018-0906-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTieger MG, Hedges TR, Ho J et al (2017) Ganglion Cell Complex Loss in Chiasmal Compression by Brain Tumors. J Neuroophthalmol 37(1):7\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/WNO.0000000000000424\u003c/span\u003e\u003cspan address=\"10.1097/WNO.0000000000000424\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoon CH, Hwang SC, Ohn YH, Park TK (2011) The Time Course of Visual Field Recovery and Changes of Retinal Ganglion Cells after Optic Chiasmal Decompression. Investig Ophthalmol Vis Sci 52(11):7966\u0026ndash;7973. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1167/iovs.11-7450\u003c/span\u003e\u003cspan address=\"10.1167/iovs.11-7450\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoo YJ, Hwang JM, Yang HK, Joo JD, Kim YH, Kim CY (2020) Prognostic value of macular ganglion cell layer thickness for visual outcome in parasellar tumors. J Neurol Sci 414:116823. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jns.2020.116823\u003c/span\u003e\u003cspan address=\"10.1016/j.jns.2020.116823\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHisanaga S, Kakeda S, Yamamoto J et al (2017) Pituitary Macroadenoma and Visual Impairment: Postoperative Outcome Prediction with Contrast-Enhanced FIESTA. Am J Neuroradiol 38(11):2067\u0026ndash;2072. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3174/ajnr.A5394\u003c/span\u003e\u003cspan address=\"10.3174/ajnr.A5394\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Y, Chen C, Huang W et al (2023) Preoperative volume of the optic chiasm is an easily obtained predictor for visual recovery of pituitary adenoma patients following endoscopic endonasal transsphenoidal surgery: a cohort study. Int J Surg 109(4):896. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/JS9.0000000000000357\u003c/span\u003e\u003cspan address=\"10.1097/JS9.0000000000000357\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuomaranta T, Raappana A, Saarela V, Liinamaa MJ (2017) Factors Affecting the Visual Outcome of Pituitary Adenoma Patients Treated with Endoscopic Transsphenoidal Surgery. World Neurosurg 105:422\u0026ndash;431. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2017.05.144\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2017.05.144\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlebauskiene B, Liutkeviciene R, Zlatkute E, Kriauciuniene L, Zaliuniene D (2018) Association of retinal nerve fibre layer thickness with quantitative magnetic resonance imaging data of the optic chiasm in pituitary adenoma patients. J Clin Neurosci 50:1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jocn.2018.01.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jocn.2018.01.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMenon S, Nair S, Kodnani A, Hegde A, Nayak R, Menon G (2023) Retinal nerve fiber layer thickness and its correlation with visual symptoms and radiological features in pituitary macroadenoma. J Neurosci Rural Pract 14(1):41\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25259/JNRP_18_2022\u003c/span\u003e\u003cspan address=\"10.25259/JNRP_18_2022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOtsu N (1979) A Threshold Selection Method from Gray-Level Histograms. IEEE Trans Syst Man Cybernetics 9(1):62\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1109/TSMC.1979.4310076\u003c/span\u003e\u003cspan address=\"10.1109/TSMC.1979.4310076\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44(3):837\u0026ndash;845\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYouden WJ (1950) Index for rating diagnostic tests. Cancer 3(1):32\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/1097-0142(1950)3:1\u0026lt;32::aid-cncr2820030106\u0026gt;3.0.co;2-3\u003c/span\u003e\u003cspan address=\"10.1002/1097-0142(1950)3:1%3C32::aid-cncr2820030106%3E3.0.co;2-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDanesh-Meyer HV, Wong A, Papchenko T et al (2015) Optical coherence tomography predicts visual outcome for pituitary tumors. J Clin Neurosci 22(7):1098\u0026ndash;1104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jocn.2015.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jocn.2015.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJacob M, Raverot G, Jouanneau E et al (2009) Predicting Visual Outcome After Treatment of Pituitary Adenomas With Optical Coherence Tomography. Am J Ophthalmol 147(1):64\u0026ndash;70e2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajo.2008.07.016\u003c/span\u003e\u003cspan address=\"10.1016/j.ajo.2008.07.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHan KE, Choi H, Kim SJ, Lee SM, Lee JE (2024) Clinical efficacy of optical coherence tomography parameters to predict the visual field outcome following pituitary adenoma surgery. PLoS ONE 19(11):e0313521. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0313521\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0313521\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee GI, Park KA, Lee D, Oh SY, Kong DS, Hong SD (2023) Predicting visual outcomes after decompression of pituitary tumours based on stratified inner-retinal layer thickness and age. Acta Ophthalmol 101(3):301\u0026ndash;309. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/aos.15281\u003c/span\u003e\u003cspan address=\"10.1111/aos.15281\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXia L, Wenhui J, Xiaowen Y et al (2022) Predictive value of macular ganglion cell-inner plexiform layer thickness in visual field defect of pituitary adenoma patients: a case-control study. Pituitary 25(4):667\u0026ndash;672. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11102-022-01248-6\u003c/span\u003e\u003cspan address=\"10.1007/s11102-022-01248-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgarwal R, Jain VK, Singh S et al (2021) Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study. Indian J Ophthalmol 69(9):2378\u0026ndash;2384. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijo.IJO_2086_20\u003c/span\u003e\u003cspan address=\"10.4103/ijo.IJO_2086_20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUvelius E, Valdemarsson S, Bengzon J, Hammar B, Siesj\u0026ouml; P (2023) Visual acuity in patients with non-functioning pituitary adenoma: Prognostic factors and long-term outcome after surgery. Brain Spine 3:102667. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bas.2023.102667\u003c/span\u003e\u003cspan address=\"10.1016/j.bas.2023.102667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi P, Zhang D, Ma S et al (2021) Consistency of pituitary adenomas: Amounts of collagen types I and III and the predictive value of T2WI MRI. Exp Ther Med 22(5):1255. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3892/etm.2021.10690\u003c/span\u003e\u003cspan address=\"10.3892/etm.2021.10690\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsposito D, Olsson DS, Ragnarsson O, Buchfelder M, Skoglund T, Johannsson G (2019) Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management. Pituitary 22(4):422\u0026ndash;434. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11102-019-00960-0\u003c/span\u003e\u003cspan address=\"10.1007/s11102-019-00960-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMolitch ME (2017) Diagnosis and Treatment of Pituitary Adenomas: A Review. JAMA 317(5):516\u0026ndash;524. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2016.19699\u003c/span\u003e\u003cspan address=\"10.1001/jama.2016.19699\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdulbaki A, Kanaan I (2017) The impact of surgical timing on visual outcome in pituitary apoplexy: Literature review and case illustration. Surg Neurol Int 8:16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2152-7806.199557\u003c/span\u003e\u003cspan address=\"10.4103/2152-7806.199557\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSahyouni R, Goshtasbi K, Choi E et al (2019) Vision Outcomes in Early versus Late Surgical Intervention of Pituitary Apoplexy: Meta-Analysis. World Neurosurg 127:52\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2019.03.133\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2019.03.133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSathe AV, Siu A, Kang KC et al (2023) Early Versus Delayed Fractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. World Neurosurg 180:e317\u0026ndash;e323. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2023.09.067\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2023.09.067\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePomeraniec IJ, Kano H, Xu Z et al (2018) Early versus late Gamma Knife radiosurgery following transsphenoidal surgery for nonfunctioning pituitary macroadenomas: a multicenter matched-cohort study. J Neurosurg 129(3):648\u0026ndash;657. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2017.5.JNS163069\u003c/span\u003e\u003cspan address=\"10.3171/2017.5.JNS163069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePomeraniec IJ, Dallapiazza RF, Xu Z, Jane JA, Sheehan JP (2016) Early versus late Gamma Knife radiosurgery following transsphenoidal resection for nonfunctioning pituitary macroadenomas: a matched cohort study. J Neurosurg 125(1):202\u0026ndash;212. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2015.5.JNS15581\u003c/span\u003e\u003cspan address=\"10.3171/2015.5.JNS15581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003eClinical Characteristics (n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFollow-up duration (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e97.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eVA (logMAR)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eVF MD (dB)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-6.61\u003c/p\u003e\n \u003cp\u003e-7.59\u003c/p\u003e\n \u003cp\u003e-8.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eRNFL thickness (\u0026micro;m)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86.4\u003c/p\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003cp\u003e81.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eOverall GCC thickness (\u0026micro;m)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.0\u003c/p\u003e\n \u003cp\u003e71.3\u003c/p\u003e\n \u003cp\u003e69.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eNasal GCC thickness (\u0026micro;m)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e69.2\u003c/p\u003e\n \u003cp\u003e69.3\u003c/p\u003e\n \u003cp\u003e67.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eTemporal GCC thickness (\u0026micro;m)\u003c/p\u003e\n \u003cp\u003e-Right eye\u003c/p\u003e\n \u003cp\u003e-Left eye\u003c/p\u003e\n \u003cp\u003e-Worse eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75.1\u003c/p\u003e\n \u003cp\u003e73.5\u003c/p\u003e\n \u003cp\u003e70.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003eMRI (n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eTumour volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eTumour Diameter in the largest dimension (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eChiasmal involvement\u003c/p\u003e\n \u003cp\u003e-Approaches but not contacting\u003c/p\u003e\n \u003cp\u003e-Abutment\u003cbr\u003e\u0026nbsp;-Displacement/compression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eOptic nerve involvement\u003c/p\u003e\n \u003cp\u003e-Approaches but not contacting\u003c/p\u003e\n \u003cp\u003e-Abutment\u003c/p\u003e\n \u003cp\u003e-Displacement/compression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRight eye\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLeft eye\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eExtension into cavernous sinus\u003c/p\u003e\n \u003cp\u003e-Yes\u003c/p\u003e\n \u003cp\u003e-No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRight eye\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLeft eye\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePreop Visual Field Defect\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone/normal\u003c/li\u003e\n \u003cli\u003eTemporal loss\u003c/li\u003e\n \u003cli\u003eCentral loss\u003c/li\u003e\n \u003cli\u003eDiffuse loss\u003c/li\u003e\n \u003cli\u003eNasal loss\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePostop Residual Tumour\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone\u003c/li\u003e\n \u003cli\u003eTrace\u003c/li\u003e\n \u003cli\u003eGross\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Clinical and MRI characteristics of patients identified with pituitary macroadenomas approaching or contacting the chiasm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eFinal VA 20/40 or better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eFinal VA 20/50 or worse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAge at surgery (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e52.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop VA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.02*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop VF (dB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e-8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e-17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.03*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop RNFL (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e81.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e69.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop GCC (\u0026micro;m)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eTotal\u003c/li\u003e\n \u003cli\u003eNasal sectors\u003c/li\u003e\n \u003cli\u003eTemporal sectors\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e69.0\u003c/p\u003e\n \u003cp\u003e64.6\u003c/p\u003e\n \u003cp\u003e73.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50.5\u003c/p\u003e\n \u003cp\u003e49.3\u003c/p\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e.01*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTumour Volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTumour diameter in the largest dimension (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eOptic Nerve Appearance\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNormal\u003c/li\u003e\n \u003cli\u003eTemporal pallor\u003c/li\u003e\n \u003cli\u003eDiffuse pallor\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.2\u003c/p\u003e\n \u003cp\u003e.99\u003c/p\u003e\n \u003cp\u003e.012\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChiasm Involvement\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo contact\u003c/li\u003e\n \u003cli\u003eAbutment\u003c/li\u003e\n \u003cli\u003eDisplacement/compression\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eOptic Nerve Involvement\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo contact\u003c/li\u003e\n \u003cli\u003eAbutment\u003c/li\u003e\n \u003cli\u003eDisplacement/Compression\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eExtension into Cavernous Sinus\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop Visual Field Defect\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone/normal\u003c/li\u003e\n \u003cli\u003eTemporal loss\u003c/li\u003e\n \u003cli\u003eCentral loss\u003c/li\u003e\n \u003cli\u003eDiffuse loss\u003c/li\u003e\n \u003cli\u003eNasal loss\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.99\u003c/p\u003e\n \u003cp\u003e.6\u003c/p\u003e\n \u003cp\u003e.99\u003c/p\u003e\n \u003cp\u003e.013\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePostop Residual Tumour\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone\u003c/li\u003e\n \u003cli\u003eTrace\u003c/li\u003e\n \u003cli\u003eGross\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.548\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eFinal VF -5dB or better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eFinal VF worse than -5dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAge at surgery (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e60.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.017*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop VA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.05*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop VF (dB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e-7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e-14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop RNFL (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e84.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e70.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop GCA (\u0026micro;m)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eTotal\u003c/li\u003e\n \u003cli\u003eNasal sectors\u003c/li\u003e\n \u003cli\u003eTemporal sectors\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71.2\u003c/p\u003e\n \u003cp\u003e66.5\u003c/p\u003e\n \u003cp\u003e75.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003cp\u003e52.4\u003c/p\u003e\n \u003cp\u003e59.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTumour Volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.024*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTumour diameter in the largest dimension (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eOptic Nerve Appearance\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNormal\u003c/li\u003e\n \u003cli\u003eTemporal pallor\u003c/li\u003e\n \u003cli\u003eDiffuse pallor\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003cp\u003e.8\u003c/p\u003e\n \u003cp\u003e.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChiasm Involvement\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo contact\u003c/li\u003e\n \u003cli\u003eAbutment\u003c/li\u003e\n \u003cli\u003eDisplacement/Compression\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eOptic Nerve Involvement\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo contact\u003c/li\u003e\n \u003cli\u003eAbutment\u003c/li\u003e\n \u003cli\u003eDisplacement/Compression\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eExtension into Cavernous Sinus\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eYes\u003c/li\u003e\n \u003cli\u003eNo\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePreop Visual Field Defect\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone/normal\u003c/li\u003e\n \u003cli\u003eTemporal loss\u003c/li\u003e\n \u003cli\u003eCentral loss\u003c/li\u003e\n \u003cli\u003eDiffuse loss\u003c/li\u003e\n \u003cli\u003eNasal loss\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.6\u003c/p\u003e\n \u003cp\u003e.7\u003c/p\u003e\n \u003cp\u003e.2\u003c/p\u003e\n \u003cp\u003e.2\u003c/p\u003e\n \u003cp\u003e.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePostop Residual Tumour\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNone\u003c/li\u003e\n \u003cli\u003eTrace\u003c/li\u003e\n \u003cli\u003eGross\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Significant at p\u0026lt;0.05\u003cbr\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eNot significant after Bonferroni correction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Clinical and MRI factors associated with visual prognosis in patients who underwent transsphenoidal resection of pituitary macroadenomas.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eSurgery within 1 year (n=38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eSurgery after 1 year or observed for 1 year (n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003ePresenting VA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003ePresenting VF MD (dB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e-3.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e-12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eRNFL thickness (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e88.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.\u003cstrong\u003e005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eGCC thickness (\u0026micro;m)\u003c/p\u003e\n \u003cp\u003e-Overall\u003c/p\u003e\n \u003cp\u003e-Nasal\u003c/p\u003e\n \u003cp\u003e-Temporal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e74.3\u003c/p\u003e\n \u003cp\u003e74.8\u003c/p\u003e\n \u003cp\u003e73.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.6\u003c/p\u003e\n \u003cp\u003e60.5\u003c/p\u003e\n \u003cp\u003e68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.17\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eTumour volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Clinical and MRI factors between those who underwent transsphenoidal resection of pituitary macroadenomas within 1 year versus those who did not. Clinical characteristics were obtained from the worse seeing eye in each patient.\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ganglion cell complex, magnetic resonance imaging, pituitary macroadenoma, retinal nerve fiber layer, visual recovery","lastPublishedDoi":"10.21203/rs.3.rs-7521873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7521873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eVisual recovery after pituitary macroadenoma decompression is unpredictable. We sought to identify clinical and radiologic predictors of visual recovery and explore visual outcomes in patients who underwent early versus late surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eRetrospective study of patients with pituitary macroadenomas approaching/contacting the chiasm at a tertiary neuro-ophthalmology practice. Clinical/demographic/MRI data was analyzed. Patients who were observed or received surgery after 1 year were identified. A final visual acuity (VA) of at least 20/40 and a final visual field mean deviation (VF MD) of -5dB or better were defined as positive outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 68 patients were included. Patients with positive VA outcomes had better preoperative VA (logMAR 0.3 vs 1.3), VF MD (-8.1dB vs -17.9dB), thicker retinal nerve fiber layer (RNFL) (81.9µm vs 69.5µm) and ganglion cell complexes (GCC) (69.0µm vs 50.5µm) than those without. VF outcomes were predicted by better preoperative VA (logMAR 0.3 vs 0.7), VF MD (-7.4dB vs -14.5dB), thicker RNFL (84.1µm vs 70.5µm) and GCC (71.2µm vs 55.6µm) measurements, and tumour volume (8.4cm\u003csup\u003e3\u003c/sup\u003e vs 18.2cm\u003csup\u003e3\u003c/sup\u003e).\u003c/p\u003e\n\u003cp\u003e30 patients with better VA (logMAR 0.2 vs 0.7), VF MD (-3.97dB vs -12.61dB), thicker RNFL (88.7µm vs 76.5µm), and GCC (74.3µm vs 64.6µm) measurements had surgery deferred. Visual outcomes were similar compared to those who had surgery within a year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePreoperative VA/VF MD/RNFL/GCC thickness may predict visual outcomes after pituitary macroadenoma resection. Future studies are required to evaluate the safety of deferring surgery, even with favourable preoperative visual parameters.\u003c/p\u003e","manuscriptTitle":"Predictors of visual outcomes in urgent or delayed pituitary macroadenoma resection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 16:05:29","doi":"10.21203/rs.3.rs-7521873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0aae2e1f-adab-44a2-a64d-ba56e48426f3","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-12T23:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 16:05:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7521873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7521873","identity":"rs-7521873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}