Our Summary

This research paper explores a unique case of a 61-year-old woman who had an uncommon condition where her optic nerves and chiasm (the part of the brain where the optic nerves cross) were abnormally attached or “tethered”. This is a rare occurrence and is often reported after treatment for a noncancerous tumor in the pituitary gland (pituitary adenoma). In this case, the woman had a condition called empty sella syndrome, where the pituitary gland shrinks or becomes flattened.

The woman came to the hospital because she was experiencing progressively worsening vision loss in both eyes. An MRI scan showed that her pituitary gland was empty and her optic chiasm had moved into the space where the pituitary gland should be.

The doctors decided to perform a minimally invasive surgery through the nose and sinus cavity (endoscopic, endonasal/trans-sphenoidal approach) to reach the optic chiasm. They were able to free the optic chiasm from its abnormal attachments and then used a graft of fat from the woman’s abdomen to support it.

Following the surgery, the woman’s vision improved. This case of a tethered optic chiasm is rare, and the successful treatment using this type of surgery and abdominal fat graft is an important finding.

FAQs

  1. What is symptomatic tethering of the optic nerves and chiasm and how does it occur?
  2. What is the endonasal/trans-sphenoidal approach to detethering surgery?
  3. What improvements were observed in the patient’s condition post detethering surgery?

Doctor’s Tip

One helpful tip a doctor might tell a patient about detethering surgery is to follow post-operative care instructions carefully to ensure proper healing and minimize the risk of complications. This may include taking prescribed medications, attending follow-up appointments, and avoiding strenuous activities until cleared by the surgeon. It is also important to communicate any concerns or changes in symptoms to the healthcare team promptly.

Suitable For

Patients who are typically recommended detethering surgery are those who present with symptoms such as progressively worsening visual field deficits, bitemporal hemianopsia, or other visual disturbances. MRI imaging may reveal herniation of the optic chiasm into the sella, indicating a tethering of the optic nerves. In some cases, patients may have a history of pituitary adenoma or empty sella syndrome, which can contribute to optic nerve tethering. Detethering surgery may be recommended in these cases to relieve pressure on the optic nerves and improve visual function.

Timeline

Before detethering surgery:

  • Patient presents with progressively worsening bitemporal hemianopsia
  • MRI brain reveals empty sella with herniation of the optic chiasm
  • Optic chiasm is tethered due to arachnoid adhesions

After detethering surgery:

  • Endoscopic, endonasal/trans-sphenoidal approach is used to detether the optic chiasm
  • Arachnoid adhesions are lysed and optic chiasm is buttressed with an abdominal fat graft
  • Patient experiences subjective and objective improvements in visual fields
  • Patient does well postoperatively

What to Ask Your Doctor

  1. What are the potential risks and complications associated with detethering surgery for the optic chiasm?
  2. What is the success rate of detethering surgery for patients with similar conditions?
  3. How long is the recovery period after detethering surgery, and what is the expected outcome in terms of visual improvement?
  4. Are there any alternative treatment options to detethering surgery that should be considered?
  5. Will I need any additional follow-up appointments or treatments after the surgery?
  6. How experienced is the surgical team in performing detethering surgery for the optic chiasm?
  7. What type of anesthesia will be used during the surgery, and what is the expected length of the procedure?
  8. Will I need to make any lifestyle changes or modifications after the surgery to support my recovery?
  9. How can I best prepare for detethering surgery, both physically and mentally?
  10. Are there any specific questions or concerns that I should discuss with the surgical team before proceeding with the surgery?

Reference

Authors: Byrne N, Kochanski RB, Tajudeen B, Byrne RW. Journal: Oper Neurosurg. 2020 Sep 15;19(4):E440-E445. doi: 10.1093/ons/opaa093. PMID: 32386310