THE OPTIC CHIASM

Contouring Accuracy Program

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 Outline
1. Refresher Course on the Optic Chiasm
A. What is the optic chiasm?
B. The functions of the optic chiasm
C. “Did you know?”
2. Locating the Optic Chiasm in Medical Images
A. Where to start? The inferior limits.
B. Contouring on axial slices
C. Contouring step-by-step guide
D. Window and level considerations
3. Special Considerations for Radiation Therapy
A. Published Dose Constraints
B. Notable Protocols

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 1A. What is the Optic Chiasm?
The optic chiasm is an X-shaped space located in the forebrain,
below the hypothalamus. The right and left optic nerve partially
intersect at the optic chiasm giving it its distinctive shape.

OPTIC
CHIASM

Structural T1-weighted MRI axial image. Dissection.

Credit: Neuropsychologia, DOI: 10.1016/j.neuropsychologia.2013.03.014 Image from Wikipedia

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 1B. The Functions of the Optic Chiasm
“The crossing over of optic nerve
fibers at the optic chiasm allows
the visual cortex to receive the
same hemispheric visual field from
both eyes. Superimposing and
processing these monocular visual
signals allow the visual cortex to
generate binocular and
stereoscopic vision.”
https://en.wikipedia.org/wiki/Optic_chiasm

“To biologists, the optic chiasm is

thought to be a turning point in
evolution. It is thought that the
crossing and uncrossing optic
nerve fibers that travel through the
optic chiasm developed in such a
way to aid in binocular vision and Credit: biology-forums.com
eye-hand coordination.”
https://www.verywell.com/optic-chiasm-3421682

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 1C. “Did You Know…?”
Eye-hand coordination
Summary fun fact & forward-facing eyes
statement here…

In the primate visual system, some retinal projections (i.e. ganglial cells) cross
the midline of the optic chiasm but a uniquely high proportion do not. The
general understanding is that this evolved from the selective advantage of
accurate depth perception and eye-hand coordination.

Matz Larsson, M.D., Ph.D. writes, “The eye-forelimb hypothesis proposes that
abundant ipsilateral retinal projections developed in the primate brain to
synthesize, in a single hemisphere, visual, tactile, proprioceptive, and motor
information about a given hand, and that this improved eye-hand coordination
and optimized the size of the brain. If accurate eye-hand coordination was a
major factor in the evolution of stereopsis, stereopsis is likely to be highly
developed for activity in the area where the hands most often operate.”

Matz Larsson, “The optic chiasm: a turning point in the evolution of eye/hand
coordination,” Frontiers in Zoology, July 2013. DOI: 10.1186/1742-9994-10-41

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 2A. Where to Start? The Inferior Limits.
MRI CT
For the optic chiasm,
we start by identifying
anatomic landmarks
that are inferior.
Inferiorly, locate the
sella turcica which is the
groove that houses the
pituitary gland. This sits
just above the sphenoid
sinus and is located
below the optic chiasm.
Note: MRI and CT at
right are for different
patients.

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 2B. Contouring on Axial Slices
Delineation of the optic chiasm is easier utilizing MR (or
fused MR/CT), Specifically T1-weighted contrast enhanced
MRI.
Eldredge et al., Red Journal 2009
The landmarks that need to be identified for contouring the
optic chiasm are:
 Optic canals
 Anterior clinoid processes of the sphenoid bone
 Internal carotid arteries on each side
 Posteriorly, the pituitary stalk or the infundibular recess

Scoccianti et al., Green Journal 2015.

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 2B. Contouring on Axial Slices

Scoccianti et al., Green Journal 2015.

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 2B. Contouring on Axial Slices
It is useful to use the reconstructed contours on a sagittal and
coronal reconstructed, as the anatomy will appear more clear
and the contours can be confirmed.

Scoccianti et al., The Green Journal 2015.

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 2C. Contouring Step-by-Step Guide
1. Identify the sella turcica which lies just beneath the chiasm
2. Scrolling upwards you will encounter the anterior and posterior
clinoids as well as the optic nerves which run from the eyeballs back
to the chiasm through the optic canals.
3. As the optic nerves track posteriorly they will connect to form the
chiasm and posteriorly there will be optic tracts taking off on the left
and right to form an “X” shape
4. Thickness of the chiasm superior to inferior is only a few mm (i.e. on
the order of 3-5 mm).
5. Posteriorly to the chiasm you will often see a small dot which is the
pituitary stalk
6. The true chiasm represents the crossing fibers at the center of the “X”;
be sure to ask your physician(s) how many mm of the optic nerves
and tracts they would like added to the chiasm structure.

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 2D. Window and Level Considerations

Window and level MRI images so that the If you only have CT (and no MRI) then your
chiasm is clearly seen relative to the job is difficult. Use a very narrow window to
surrounding fluid and tissue. see the optic nerves as they exit the canals.

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 3A. Published Dose Constraints
Dose/fx Volume Max Dose Protocol Treatment Organ
33 fxs 50 Gy RTOG 0615 Nasopharynx
1.8-2.0 Gy 0.03 cc 54 Gy RTOG 0539 Intermediate risk
meningioma
1.8-2.0 Gy 0.03 cc 56 Gy RTOG 0539 High risk
RTOG 0825 meningioma,
Glioblastoma

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 3B. Notable Protocols
RTOG 0615
A Phase II Study of Concurrent Chemoradiotherapy Using Three-
Dimensional Conformal Radiotherapy (3D-CRT) or Intensity-Modulated
Radiation Therapy (IMRT) + Bevacizumab (BV) For Locally or
Regionally Advanced Nasopharyngeal Cancer
RTOG 0539
Phase II Trial of Observation for Low-Risk Meningiomas and of
Radiotherapy for Intermediate- and High-Risk Meningiomas
RTOG 0825
Phase III Double-Blind Placebo-Controlled Trial of Conventional
Concurrent Chemoradiation and Adjuvant Temozolomide Plus
Bevacizumab versus Conventional Concurrent Chemoradiation and
Adjuvant Temozolomide in Patients with Newly Diagnosed
Glioblastoma

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