[Year]

[Document title]

Ahmed saber
[Company name]
[Date]
Diffinition :
Bitemporal hemianobia caused by tumor compression.

Hard terms:
After reading the case well I found some difficult terms that I needed to translate:
- Vague : not clear.
- gaze : to look steadily.
- Ishihara : is a color perception test for red-green color deficiencies.

Identification:
A 53 years old male with type 2 diabetes ,mild non proliferative retinopathy ,with
slowly progressed reading difficulty with distorted temporal vision (bitemporal
hemianopia),highly photophopic with pituitary macroadenoma stretching optic
chiasm.
Problem analysis:

After reading problem well and depending on the patient information:

-The patient is an old man has type 2 diabetes.
-His ocular health was normal but he had mild non-proliferative retinopathy:
Retinopathy is almost one of complications of type 2 diabetes.
-He has both eyes abnormal refraction.
-No ocular disease in his family history :
that means there is something wrong with his eyes but non congenital.
-He has problems in reading and focusing progressed with age and stress, left eye
distortion and no headache.
-His right eye visual acuity was 6/5 and left eye was 6/12 to 6/24 :
that means the problem is in the left eye.
-During fundus examination the patient showed photophobia in the left eye.
-Intra ocular pressure , colour vision, confrontation visual field test were all
normal : normal ocular pressure means no masses in orbit cavity.
-Amsler grid test showed positive distortion, Bitemporal hemianopia was detected:
the condition of hemianopia is almost because problems in optic chiasm.
-Pituitary macroadenoma detected compressing optic chiasm and optic nerves.
Pituitary hormones were normal except LH&FSH:
That means the macroadenoma is in the part that secrets LH & FSH.
-After surgical removal of macroadenoma his visual acuity restored:
that means the tumor was compressing the optic chiasm causing vision problems.

Generating and testing hypothesis:

1-congenital cause: the cause may be congenial disorder causing eye deformity.
- this hypothesis is not possible because the patient has no family history of ocular
disease.
2-Ocular inflammation: the problem may be due to inflammation of the eye due to
infection or irritation.
-this hypothesis is not possible because no abnormalities(redness or any sign of
inflammation) were seen in retina or optic nerve head in either eyes using slit
lamp fundoscopy.
3- Trauma: The patient may exposed to trauma in his eye or head that may affect
his vision.
-the patient did not mention something like that.
4-Tumor: the cause may be a tumor in the orbit compressing the eye or nerves.
-this is a logic hypothesis but has a small gap that there is not headache and the
intra ocular pressure is normal.
5-The problem may be neural due to problem in primary visual cortex or lateral
geniculate nucleus or optic chiasma or nerves:
This hypothesis seems the most logic one among them.
The deferential diagnosis: pituitary adenoma compresses the optic chiasma
causing bitemporal hemianopia.

Objectives:
1-structure of the eye.
2-Nerve supply of the eye.
3-Vision cascade (optic pathway).
4- Bitemporal hemianopia.
5-overview about pituitary gland anatomy.
6-Pituitary gland adenomas.

1-structure of the eye:

The major structures of the eye are illustrated in Figure below. The wall of the eye
consists of three concentric layers: an outer layer, a middle layer, and an inner
layer. The outer layer, which is fibrous, includes the cornea, corneal epithelium,
conjunctiva, and sclera. The middle layer, which is vascular, includes the iris and
the choroid. The inner layer, which is neural, contains the retina. The functional
portions of the retina cover the entire posterior eye, with the exception of the blind
spot, which is the optic disc (head of the optic nerve). Visual acuity is highest at a
central point of the retina, called the macula; light is focused at a depression in the
macula, called the fovea. The eye also contains a lens, which focuses light;
pigments, which absorb light and reduce scatter; and two fluids, aqueous and
vitreous humors. Aqueous humor fills the anterior chamber of the eye, and vitreous
humor fills the posterior chamber of the eye. The sensory receptors for vision are
photoreceptors, which are located on the retina. There are two types of
photoreceptors, rods and cones. Rods have low thresholds, are sensitive to low-
intensity light, and function well in darkness. The rods have low acuity and do not
participate in color vision. Cones have a higher threshold for light than the rods,
operate best in daylight, provide higher visual acuity, and participate in color
vision. The cones are not sensitive to low intensity light. Information is received
and transduced by photoreceptors on the retina and then is carried to the CNS via
axons of retinal ganglion cells. Some optic nerves cross at the optic chiasm, and
others continue ipsilaterally.(2)

2-Nerve supply of the eye:

The optic nerve (CN II) conveys visual information. These nerves are paired,
anterior extensions of the forebrain (diencephalon) and are, therefore, CNS fiber
tracts formed by axons of retinal ganglion cells. CN II is surrounded by extensions
of the cranial meninges and subarachnoid space, which is filled with CSF. CN II
begins where the unmyelinated axons of the retinal ganglion cells pierce the sclera
and become myelinated, deep to the optic disc. The optic nerve passes
posteromedially in the orbit, exiting through the optic canal to enter the middle
cranial fossa where it forms the optic chiasm . Here, fibers from the nasal (medial)
half of each retina decussate in the chiasm and join uncrossed fibers from the
temporal (lateral) half of the retina to form the optic tract. The partial crossing of
optic nerve fibers in the chiasm is a requirement for binocular vision, allowing
depth-of-field perception (three-dimensional vision). Thus, fibers from the right
halves of both retinas form the right optic tract and those from the left halves form
the left optic tract. The decussation of nerve fibers in the chiasm results in the right
optic tract conveying impulses from the left visual field and vice versa. The visual
field is what is seen by a person with both eyes wide open and looking straight
ahead. Most fibers in the optic tracts terminate in the lateral geniculate bodies
(nuclei) of the thalamus. From these nuclei, axons are relayed to the visual cortices
of the occipital lobes of the brain.
The oculomotor nerve (CN III) provides the following:
•Somatic motor innervation to four of the six extra-ocular muscles (superior,
medial, and inferior rectus and inferior oblique) and to the levator palpebrae
superioris.
• Proprioceptive innervation to the previous muscles.
• Visceral (parasympathetic) innervation through the ciliary ganglion to the
smooth muscle of the sphincter pupillae, which causes constriction of the pupil and
ciliary muscle to produce accommodation (allowing the lens to become more
rounded) for near vision.(1)

3-Visual cascade (optic pathways):

The optic pathways from the retina to the CNS are shown in this figure:
 Axons from retinal ganglion cells form the optic nerves and optic tracts, synapse
in the lateral geniculate body of the thalamus, and ascend to the visual cortex in the
geniculocalcarine tract. Notice that the temporal visual fields project onto the nasal
retina, and the nasal fields project onto the temporal retina. Nerve fibers from each
nasal hemiretina cross at the optic chiasm and ascend contralaterally. Nerve fibers
from each temporal hemiretina remain uncrossed and ascend ipsilaterally. Thus
fibers from the left nasal hemiretina and fibers from the right temporal hemiretina
form the right optic tract and synapse on the right lateral geniculate body.
Conversely, fibers from the right nasal hemiretina and fibers from the left temporal
hemiretina form the left optic tract and synapse on the left lateral geniculate body.
Fibers from the lateral geniculate body form the geniculocalcarine tract, which
ascends to the visual cortex (area 17 of the occipital lobe). Fibers from the right
lateral geniculate body form the right geniculocalcarine tract; fibers from the left
lateral geniculate body form the left geniculocalcarine tract.
Lesions at various points in the optic pathway cause deficits in vision, which can
be predicted by tracing the pathway, as shown in Figure 3.19. Hemianopia is the
loss of vision in half the visual field of one or both eyes. If the loss occurs on the
same side of the body as the lesion, it is called ipsilateral; if the loss occurs on the
opposite side of the body as the lesion, it is called contralateral.
1-Optic nerve: Cutting the optic nerve causes blindness in the ipsilateral (same
side) eye. Thus cutting the left optic nerve causes blindness in the left eye. All
sensory information coming from that eye is lost because the cut occurs before any
fibers cross at the optic chiasm.
2-Optic chiasm: Cutting the optic chiasm causes heteronymous (both eyes)
bitemporal (both temporal visual fields) hemianopia. In other words, all
information is lost from fibers that cross. Thus information from the temporal
visual fields from both eyes is lost because these fibers cross at the optic chiasm.
3-Optic tract: Cutting the optic tract causes homonymous contralateral
hemianopia. As shown in the figure, cutting the left optic tract results in loss of the
temporal visual field from the right eye (crossed) and loss of the nasal visual field
from the left eye (uncrossed).
4- Geniculocalcarine tract: Cutting the geniculocalcarine tract causes
homonymous contralateral hemianopia with macular sparing (the visual field
from the macula is intact). Macular sparing occurs because lesions of the visual
cortex do not destroy all neurons that represent the macula.(2)

4-Bitemporal hemianopsia

(or Bitemporal hemianopia) is the medical description of a type of partial

blindness where vision is missing in the outer half of both the right and left visual
field.

It is usually associated with lesions of the optic chiasm, the area where the optic
nerves from the right and left eyes cross near the pituitary gland.

In bitemporal hemianopsia vision is missing in the outer (temporal or lateral) half

of both the right and left visual fields.

Information from the temporal visual field falls on the nasal (medial) retina.
The nasal retina is responsible for carrying the information along the optic nerve,
and crosses to the other side at the optic chiasm.

When there is compression at optic chiasm the visual impulse from both nasal
retina are affected, leading to inability to view the temporal, or peripheral, vision.

This phenomenon is known as bitemporal hemianopsia.

Knowing the neurocircuitry of visual signal flow through the optic tract is very
important in understanding bitemporal hemianopsia.

Bitemporal hemianopsia most commonly occurs as a result of tumors located at the

mid-optic chiasm.

Since the adjacent structure is the pituitary gland, some common tumors causing
compression are Pituitary adenomas, and Craniopharyngiomas.

Also another relatively common neoplastic etiology is Meningiomas.

The absence of vision in half of a visual field is described as hemianopsia.

The visual field of each eye can be divided in two vertically, with the outer half
being described as temporal, and the inner half being described as nasal.
"Bitemporal hemianopsia" can be broken down as follows: bi-: involves both left
and right visual fields temporal: involves the temporal visual field hemi-: involves
half of each visual field anopsia: blindness.(4)
5-overview about pituitary gland anatomy:

The pituitary gland lies in a bony hollow of the sphenoid (the sella turcica), and it
is covered by the fibrous diaphragm masellae.
The optic chiasma lies directly superior to the anterior pituitary. The posterior lobe
is connected to the median eminence of the hypothalamus by the pituitary stalk
(also known as the infundibulum). The pituitary gland is divided into two lobes
with distinct embryological origins, structure and function:
• Anterior pituitary (also known as adenohypophysis).
• Posterior pituitary(also know nasneurohypophysis). The cavernous sinuses,
including cranial nerves III–VI, lie laterally.(1)

6-Pituitary gland adenomas:

These are the most common type of pituitary tumour and do not produce
hormones. They are most commonly non-functioning gonadotroph cells. Since
there is no excess hormone production they usually present late with symptoms
caused by compression of surrounding structures.
Symptoms are usually progressive:
• Headache, vomiting and papilloedema due to raised intracranial pressure
• Visual disturbance
• Oligomenorrhoea and amenorrhoea in women
• Reduced libido and infertility in men
• Cranial nerve palsies.
The tumour can cause hormone deficiencies by direct compression of the secretory
cells or by compressing the portal veins that bring the hypothalamic-releasing
factors. Secretion of anterior pituitary hormones is inhibited in a characteristic
order: GH, LH, FSH, ACTH, TSH,prolactin.
Unless the compression is severe, prolactin secretion often increases.(3)

Synthesis and solutions:

After reading problem well, analyse it, generating and testing hypothesis and
finally using previous knowledge and self learning to try to solve the problem I
found that:
-Optic pathway starts by the eye ball which has a neural part which called retina.
-Retina is directly connected to the optic nerve which carries the visual impulse to
the brain to make clear image.
- as we know the optic nerves meets above the pituitary gland forming the optic
chiasma.
-At the optic chiasma, the optic nerve fibers of the nasal half of the eye cross to the
opposite side, where it joins the fibers from the opposite temporal retina to form
the optic tracts.
-So we get that any problem in the optic chiasma can effect temporal visual field.
-In the problem the patient has a pituitary gland adenoma and by dependence on
the case (bilateral missing prepheral vission) The tumor compressing on the optic
chiasma and causes bitemporal heminanopia.
The solving of this problem: is surgecal removal of the tumor after removal
nothing will compress the optic chiasma so the bitemoral hemianopia will be
treated.
References :
1-Moore, Keith L., Anne MR Agur, Arthur F. Dalley,
and Keith L. Moore. Essential clinical anatomy.
Wolters Kluwer Health,, 2015.
2-Costanzo, Linda S. Physiology. Philadelphia:Wolters
Kluwer, 2019.
3-Sattar, Husain A. Fundamentals of Pathology:
Medical Course and Step 1 Review. Chicago, IL:
Pathoma.com, 2018.

4- Kosmorsky, Gregory S., William J. Dupps Jr, and

Richard L. Drake. "Nonuniform pressure generation
in the optic chiasm may explain bitemporal
hemianopsia." Ophthalmology 115, no. 3 (2008): 560-
565.