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NEURO OPHTHALMOLOGICAL MANIFESTATIONS IN PATIENTS OPERATED FOR CEREBELLOPONTINE ANGLE
TUMORS
Vitovska O. P.
Konakh V. M.
Vasyuta V. A.
Department of Ophatalmology, Bogomolets National Medical University The State Institution "Institute of Neurosurgery named after A.P. Romodanov ofAMS of Ukraine"
Abstract. The present article is concerned with the study of neuro-ophthalmological manifestations observed in patients with cerebellopontine angle (CPA) tumors before surgery and in early postoperative period. Analysis of visometry with correction demonstrated postoperative decrease in visual acuity. 67 patients presented with lagophthalmos at the operated side and biomicroscopy with fluorescein test showed signs of epitheliopathy. 73.1% of patients had reduced corneal sensitivity in eyes affected with lagophthalmos. Tear production and tear film break-up time significantly decreased (p<0.05). In early postoperative period, the number of patients with normal
ocular fundus increased (48.9% versus 42.7% before surgery ^<0.05). More patients presented with oculomotor disturbances, and in 78.2% ofpatients, the functional status remained high.
Keywords: Cerebellopontine angle tumors, oculomotor disturbances, tear production, dry eye syndrome, and corneal reflex.
Introduction. Over the last years, the incidence of brain tumors has been increasing worldwide, including countries with high standard of living. According to National Cancer Registry of Ukraine, in 2009 primary intracranial neoplasms accounted for 4.35 cases, in 2010 - 4.71 cases, while in 2012 - 6.6 cases per 100,000 population. CPA tumors, due to their location, occupy a special place among other neoplasms because these tumors tightly adhere in the course of their development to facial and trigeminal nerves and as they grow large, occupy the cerebellopontine angle completely, squeezing out the cerebellum, brainstem and cerebral nerves [4].
For that very reason, damage of facial and trigeminal nerves during surgery for tumor removal occurs rather often and results in the development of lagophthalmos and subsequent secondary dry eye syndrome and neurotrophic keratopathy. CPA tumors account for 12-13% of the brain tumors [1, 3, 4, 5].
Materials and methods. The study included 178 patients (66 men and 112 women) with CPA tumors treated in 2009-2011 at the hospital of infratentorial tumors of the State Institution "Institute of Neurosurgery named after A.P. Romodanov of AMS of Ukraine." All the patients underwent surgery for removal of CPA tumors. Ophthalmologic examination included measurement of visual acuity with correction, test for lagophthalmos, assessment of corneal sensitivity according to corneal reflex, and assessment of oculomotor system, including measurement of functional status by V.M. Zhdanova (2009) [2] (scores 45-31 reflected relatively high functional status, 30-16 - moderate or good and 0-15 - low or unsatisfactory functional status), biomicroscopy with fluorescein test, determination of tear film break-up time, and tear production (Shirmer and Jones test).
Results and discussion. All hospitalized patients with CPA tumors were aged 21-70 years. Sex structure analysis of inpatients revealed higher incidence of CPA tumors in women. In particular, during the study period 62.6% women were diagnosed with CPA tumors, as compared to 37.4% men.
Among postoperative complaints, the most common were about inability to close eyelid completely - 67 patients, and eye dryness - 63 patients, which is 37.6% and 35.4%, respectively. These complaints depended upon the type and specifics of performed neurosurgical intervention. Lagophthalmos occurred in all the cases of facial nerve damage during surgery.
Inability to close eyelid completely led to signs of eye bulb dryness. Lagophthalmos was always unilateral and occurred at the side of facial nerve damage.
Increased number of patients with reduction in vision (34.3% versus 30.9%) can be explained by several factors. Firstly, part of surgically treated patients develop neurotrophic corneal changes that may result in visual deterioration. Secondly, in early postoperative period patients may have slightly deferred reactions due to the effect of anesthesia and other medicinal products, which may also impair visual acuity.
Sometimes patients complained about double vision, lacrimation and eye pain.
Blurred vision occurred with lower incidence - in 13.1% of patients versus 24.6% before surgery. This is due to the decreased number of intracranial hypertension in patients that underwent surgery for removal of CPA tumors.
Table 1 represents corrected visual acuity data in early postoperative period in patients following surgery for CPA neoplasms.
According to Table 1, visual acuity decreased in early postoperative period as compared to preoperative period. This is due to the development of neurotrophic keratitis in some patients since the deterioration of visual function occurs only in the eyes affected with neuroparalytic keratitis.
Accordingly, following the removal of CPA neoplasms there is seen reduction of visual function in early postoperative period. Two things account for that: development of neurotrophic keratitis of various degree of severity and effect of medicinal products and anesthetics on postoperative patients that results in deferred reactions, which subside with time.
Patients with CPA neoplasms undergo biomicroscopy in early postoperative period for detailed examination of conjunctiva and cornea. Ocular surface dye with 1% sodium fluorescein solution was used as a tool to diagnose epitheliopathy.
These patients presented with lagophthalmos at the side of surgery. It should be noted that dyed areas were located within open eye fissure, contrary to degenerative and inflammatory changes.
The results of fluorescein dying of conjunctiva and cornea in patients that underwent surgery for CPA tumors in early postoperative period were as follows: scores of fluorescein dying of cornea and bulbar conjunctiva - 4.92±4.3 and 1.25±1.9, respectively.
Table 1. Visual acuity data in early postoperative period for patients that underwent surgery for CPA tumors (n=178)
Period Visual acuity Eye in relation to tumor
ipsilateral contralateral
before surgery after surgery before surgery after surgery
abs.nr. % abs.nr. % abs. nr. % abs.nr. %
1.0 109 61.2 91 51.1 116 65.2 113 63.5
0.7-0.9 51 28.7 52 29.2 46 25.8 46 25.8
0.4-0.6 11 6.2 24 13.5 12 6.7 13 7.3
0.1-0.3 6 3.4 10 5.6 2 1.1 5 2.8
0.05-light sensitivity 1 0.6 1 0.6 1 0.6 1 0.6
Total 178 100.0 178 100.0 178 100.0 178 100.0
Corneal reflex assessment was mandatory for all the patients in early postoperative period. 72.4% of patients with lagophthalmos had reduced corneal reflex.
67 patients in early postoperative period had unilateral lagophthalmos occurring at the side of damaged facial nerve. This manifestation was accompanied at the damaged side by changes in both, baseline and general tear production, and tear film stability disorder (Table 2).
When comparing the results with the state of eye lubrication before surgery, there was seen significant worsening of lubrication - reduced tear production (p<0.05) and tear break-up time (p<0.05) values.
Table 2. Eye lubrication in patients with lagophthalmos resulting from facial nerve damage during surgery for CPA tumor removal
Statistical values Test
Patients Jones (mm/5min) Shirmer (mm/5min) Tear break-up time (sec)
Reference group (M+m) n 16.5±0.3 30 28.5±0.7 30 18.3±1.2 30
Before surgery (M+m) n 12.3±1.7 178 17.2±3.3 178 12.3±1.9 178
With lagophthalmos following surgery (M+m) n 5.5±3.1 67 9.2±3.8 67 4.8±1.9 67
P1 <0.05 <0.05 p<0.05
P2 <0.05 <0.05 p<0.05
Dynamics of changes in ocular fundus is essential for neurosurgeons as this shows whether the intracranial pressure decreases successfully in postoperative period. That is why following neurosurgical intervention in CPA all the patients undergo careful examination of ocular fundus. The results of examination are given in Table 3.
The number of patients with normal ocular fundus slightly increased in early postoperative period: 48.9% versus 42.7% before surgery (p<0.05). This is due to the fact that less patients had papilledema (23.6%), when compared to 29.7% prior to surgical intervention (p<0.05). 27.5% of patients presented with vascular changes in ocular fundus - retinal angiopathy, manifesting as venous dilation, arteriostenosis. The number of patients in this group remained the same.
Table 3. Data of ophthalmoscopy in patients that underwent surgery for CPA tumors, in early postoperative period (n=178)
Period Before surgery After surgery
Parameters abs.nr. % abs.nr. %
Normal ocular fundus 76 42.7 87 48.9 <0.05
Papilledema 53 29.7 42 23.6 <0.05
Retinal angiopathy 49 27.6 49 27.5 >0.05
Total patients 178 100 178 100
Results of the study of oculomotor disorders in patients that underwent surgery for CPA tumors are given in Table 4.
Table 4. Affected cerebral nerves in patients that underwent surgery for CPA tumors, in early postoperative period
Period Before surgery After surgery
Nerve abs.nr. % abs.nr. %
III (oculomotor nerve) 4 2.2 6 3.4
IV (forth cranial nerve) 2 1.1 1 0.6
VI (abducent nerve) 7 3.9 7 3.9
IV, VI 7 3.9 6 3.4
III, IV ,VI 9 5.1 11 6.2
Total 29 16.3 31 17.4
Results of comparison of oculomotor disorders before and after the surgery show that the number of patients presenting with the said changes slightly increased in early postoperative period (17.4% versus 16.3% prior to surgery; р>0.05).
Functional status in patients with oculomotor disorders was assessed using special scale proposed by V.M. Zhdanova [2]. The study analyzed functional status of subjects with oculomotor disorders resulting from CPA neoplasms according to the table above.
The majority of patients (78.2%) had relatively high status and yet worse than before surgery.
Conclusions. The study assessed ophthalmological status in patients with CPA tumors prior to and following the surgical treatment - removal of CPA tumor. Patients' complaints analysis in post- and preoperative periods showed changes in the incidence of some complaints: 63 (35.4%) patients reported during ophthalmologic examination eye dryness and 67 (37.6%) patients complained about inability to close eyelid completely at the side of neoplasm. Nearly one third of patients - 61 (34.3%) - reported deterioration of vision. Important positive trend is the reduced number of patients suffering from blurred vision - 23 (13.1%) due to decreased intracranial hypertension.
According to visometry, visual acuity in early postoperative period decreased compared to that before surgery. The study found development of neurotrophic keratitis of various degree of severity.
In early postoperative period, 67 (37.6%) eyes presented with signs of corneal damage of various degrees of severity at the side of tumor removal. Such patients had lagophthalmos at the side of surgical intervention and their biomicroscopy showed areas of epitheliopathy.
73.1% of patients with lagophthalmos had reduced corneal reflex.
When comparing the results with the state of eye lubrication before surgery, there was seen significant worsening of lubrication - reduced tear production (р<0.05) and tear break-up time (р<0.05) values, which is indicative of dry eye syndrome progression.
In early postoperative period, the number of patients with normal ocular fundus slightly increased (48.9% versus 42.7% before surgery (р<0.05). This is due to the fact that less patients had papilledema (23.6%), when compared to 29.7% prior to surgical intervention (p<0.05).
Results of comparison of oculomotor disorders before and after the surgery show that the number of patients presenting with the said changes slightly increased in early postoperative period (17.4% versus 16.3% prior to surgery; р>0.05).
The majority of patients (78.2%) had relatively high status with regard to oculomotor disorders, however worse than before surgery (р<0.05). Consequently, postoperative period is characterized by poorer subjective evaluations and deterioration of patients' functional status.
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