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Profile of brain tumors having ocular manifestations in a Tertiary Eye Care

Institute: A retrospective study

Article  in  TNOA Journal of Ophthalmic Science and Research · August 2018

DOI: 10.4103/tjosr.tjosr_49_18

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Original Article

Profile of Brain Tumors Having Ocular Manifestations in a

Tertiary Eye Care Institute: A Retrospective Study
Saurabh Deshmukh, Dipankar Das1, Harsha Bhattacharjee2, Ganesh Ch Kuri3, Damaris Magdalene4, Krati Gupta, Prabhjot Kaur Multani,
Vivek Paulbuddhe, Shriya Dhar
Departments of Ophthalmology, 1Ocular Pathology, Uveitis and Neuro‑Ophthalmology, 2Vitreo‑Retina Surgery, 3Ophthalmic Plastic and Reconstructive Surgery and
4
Pediatric Ophthalmology and Strabismus, Sri Sankaradeva Nethralaya, Guwahati, Assam, India

Abstract
Aim: To form a profile of brain tumors having ocular manifestations presenting to a tertiary eye care institute. Materials and Methods: The
medical records of patients diagnosed with primary brain tumors between January 2012 and December 2017 were reviewed. Patients underwent
a detailed ocular examination and neuroimaging to confirm the diagnosis. Results: Out of the 17 patients, 11 (65%) were female and 6 (35%)
were male. The mean age was found to be 43.17 ± 11.04 years and the majority of the patients belonged to the age group 21–40 years (47.06%).
The most common presenting symptom was found to be diminution of vision (100%), followed by headache (41.14%) and vertigo (23.52%).
The most common sign was optic disc changes, namely optic atrophy (47.05%), followed by disc pallor (29.41%) and papilledema (11.76%).
Meningioma (41%) was the most common tumor followed by pituitary macroadenomas (29%). At the time of presentation, two patients had
the restriction of extraocular movements, seven patients had a positive relative afferent pupillary defect, and four had defective color vision.
Conclusions: Ophthalmic signs and symptoms form a major part of the presentation in patients with intracranial tumors. Majority of the
patients diagnosed by ophthalmologists with brain tumors presented with optic disc pallor or edema resulting in diminution of vision. By
careful neuro‑ophthalmic evaluation, early diagnosis of intracranial space occupying lesions can be made and prompt referral to neurosurgeon
can reduce the morbidity and mortality.

Keywords: Intracranial tumors, neuro‑ophthalmology, ophthalmic manifestation, visual fields, visual impairment

Introduction ophthalmologists play a crucial role in early diagnosis and

A primary brain tumor is one of the most common and important
reasons for seeking neurological and ophthalmological
consultation worldwide.[1‑3] The clinical signs and symptoms
and management of these tumors depends on the site, type,
and duration of the tumor. The clinical features are related
to mass effect, raised intracranial tension, or expression or
suppression of various hormones by the tumors or due to
hydrocephalus.[4,5] These clinical presentations are caused
due to the involvement of the visual pathway, including
cranial nerves  (CNs), their tracts, and cranial nuclei.[3,5‑11]
Ophthalmic signs and symptoms include vision loss, ptosis,
paresis or paralysis of extraocular movements, diplopia,
and optic disc changes.[7] About 46.8%–88.6% of patients
present with neuro‑ophthalmological manifestations.[3,7,10,11]
About 60% of these patients with brain tumor present first
to an ophthalmologist with ocular complaints.[12] Thus, the
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appropriate referral to the neurosurgeon and endocrinologist.
The purpose of this study was to form a profile of the
intracranial tumors presenting to the neuro‑ophthalmology
clinic in a tertiary eye care institute.
Materials and Methods
This retrospective study included 17 patients diagnosed with
primary brain tumors at a tertiary eye care institute in Northeast
India between January 2012 and December 2017 after approval
by the institutional ethics committee. Medical records of each
Address for correspondence: Dr. Saurabh Deshmukh,
Department of Ophthalmology, Sri Sankaradeva Nethralaya,
96, Basistha Road, Beltola, Guwahati ‑ 781 028, Assam, India.
E‑mail: dr.saurabh89@gmail.com
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For reprints contact: reprints@medknow.com

How to cite this article: Deshmukh S, Das D, Bhattacharjee H, Kuri GC,

DOI: Magdalene D, Gupta K, et al. Profile of brain tumors having ocular
10.4103/tjosr.tjosr_49_18 manifestations in a Tertiary Eye Care Institute: A retrospective study. TNOA
J Ophthalmic Sci Res 2018;56:71-5.

© 2018 TNOA Journal of Ophthalmic Science and Research | Published by Wolters Kluwer - Medknow 71
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Deshmukh, et al.: Ophthalmic manifestations of brain tumors
patient were reviewed. A detailed history was taken from the
patient as well as from the attendants. Onset, duration, and
progress of symptoms such as the blurring of vision, eye pain,
headache with or without aura, vomiting, diplopia, proptosis,
and drooping of eyelids were noted. History of illness,
hypertension, diabetes mellitus, ischemic heart disease, asthma,
tuberculosis, substance abuse, other medication, and infection
were noted. The detailed ophthalmological examination was
done including assessment of uncorrected visual acuity, pinhole
vision, best‑corrected visual acuity, ocular movements in
all nine cardinal gazes, nystagmus, squint assessment using
cover and alternate cover test, pupil examination for the
relative afferent pupillary defect  (RAPD), and color vision
test  (Ishihara’s chart). Slit‑lamp examination of anterior
segment was done. Posterior segment was examined using slit
lamp with +90 diopter lens and using indirect ophthalmoscope
with +20 diopter lenses. Intraocular pressure was measured by
Goldmann applanation tonometry. Diplopia charting was done
for patients complaining of diplopia. Hess charting was done to
measure the degree of deviation, torsion, and also for follow‑up
in all cases of diplopia. Any abnormality in head posture
caused due to diplopia was noted. The palpebral apertures
were compared and any abnormal widening because of lid
retraction or proptosis was noted. If proptosis was detected, its
measurement was taken and direction was noted. Similarly, a
detailed examination was also done for ptosis. All the CNs were
systematically examined. First CN was examined by testing
each nostril separately for a sense of smell using the coffee
beans. The second CN was assessed using the visual acuity,
pupillary reactions, visual field assessment, and visualizing the
optic nerve head. The third, fourth, and sixth CNs were assessed
by examination of ocular motility in all nine cardinal gazes.
Fifth CN, motor part was tested by palpating the temporalis
and the muscles of mastication when the patient clenched his
teeth and sensory part was tested by checking for sensations in
all three dermatomes. The patient was asked to crease up the
forehead, reveal the teeth, and puff out the cheeks to test for
the seventh CN. Bell’s phenomenon was also elicited. Weber’s
and Rinne’s test were performed using tuning fork to check for
the eighth CN. Ninth and tenth CN were tested by performing
gag reflex and asking to patient say Ah and checking for the
palatal arches. Eleventh CN was tested by asking the patient
to shrug his shoulders against resistance and to rotate his
head against resistance. Twelfth CN was tested by asking the
patient to put out his tongue and observing for any wasting or
deviation. Central nervous system examination was performed
by checking for orientation and short and long‑term memory.
The tone in the muscles and reflexes were elicited. Coordination
was tested using the finger‑nose test and dysdiadochokinesis.
Sensations were checked using pinprick test, temperature sense,
vibration sense, and joint and position sense. Fundus and optic
disc photography was done. Automated perimetry (Humphrey
visual field 30‑2, 10‑2) was done for visual field defects. Visual
evoked potential was done. To confirm the clinical diagnosis and
ascertain the site of lesion, magnetic resonance imaging (MRI)
of brain and orbit was performed.
72 TNOA Journal of Ophthalmic Science and Research ¦ Volume 56 ¦ Issue 2 ¦ April-June 2018
Results
A total of 17  patients were evaluated. The mean age was
43.17 ± 11.04 years. Of the 17 patients, 47.06% (n = 8) were
in the 21–40  years’ age group, 41.18%  (n  =  7) were in the
41–60 years’ age group, and 5.88% (n = 1) each in 0–20 and
61 and above years’ age group [Figure 1a].
Of the 17  patients, 64.71%  (n  =  11) were female and
35.29%  (n  =  6) were male  [Figure  1b]. There were 100%
female patients  (n  =  1) and 0%  (n  =  0) male patient in
0–20 years age group, 50% female patients (n = 4) and 50%
male patients  (n  =  4) in 21–40  years’ age group, 71.43%
female patients (n = 5) and 28.57% male patients (n = 2) in
41–60 years’ age group, and 100% female patients (n = 1) and
0% (n = 0) male patients in 61 years and above age group of
patients.
The visual acuity of the worse eye was taken into account.
The visual acuity was poor in most of the patients at the time
of presentation, that is, 6/36 or less in 70.58% (n = 12) of the
patients. 23.52% (n = 4) of the patients had a visual acuity of
6/6–6/12, and 5.88% (n = 1) had visual acuity between 6/12
and 6/36 [Figure 2].
The patients presented with a wide variety of
symptoms [Figure 3a]. All patients presented with diminution
of vision  (n  =  17). The second most common symptom
was a headache, present in 41.17%  (n  =  7) of the patients,
followed by vertigo in 23.52% (n = 4), vomiting and tinnitus
in 11.76% (n = 2) of the patients each. 5.88% (n = 1) patients
presented with diplopia, facial swelling, epistaxis, arthritis,
pallor, and ptosis each.
The most common ocular sign which we observed was optic
disc atrophy, seen in 47.05%  (n  =  8) of the patients. Optic
disc pallor was seen in 29.41%  (n  =  5) and papilledema
in 11.76%  (n  =  2) of the patients. One patient had retinal
pigment epithelial defects and one had normal looking fundus.
11.76% (n = 2) of the patients showed restriction of extraocular
movements. One patient had a restriction of movement in up
gaze and one had a restriction in all gazes. RAPD was seen
in 41.17% (n = 7) of the patients at the time of presentation.
23.52% (n = 4) of the patients had defective color vision at
the time of presentation [Figure 3b].
11.76%  (n  =  2) of the patients had a normal visual field.
Quadrantanopia was seen in 5 (29.41%) patients, while 7
a b
Figure 1: (a) Age group-wise distribution of patients. (b) Gender-wise
distribution of patients
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Deshmukh, et al.: Ophthalmic manifestations of brain tumors
(41.18%) had hemianopia and 3 (17.65%) had a three quadrant
or more visual field loss. [Figure 4].
Meningioma was the most common tumor observed in this
study, with a prevalence of 41.17% (n = 7). The next most
common tumor encountered was pituitary macroadenoma, which
was seen in 29.41% (n = 5) of the patients. Craniopharyngioma
and posterior fossa tumor were seen in 11.76% (n = 2) of the
patients. Intracranial space‑occupying lesion (ICSOL) was seen
in 5.88% (n = 1) of the patients [Figure 5].
Discussion
Studies have shown that about 80% of primary brain tumors
occur in adults and 20% in the pediatric age group.[13] Primary
brain tumors are the second most common solid tumor in
children. Approximately 70% of the brain tumors have glial cell
origin whereas 15% of them originate from the meninges. The
location of the brain tumor varies with age, in adults 70% are
supratentorial, whereas in children 70% are infratentorial.[14]
Among the neurological diseases, intracranial tumors are
the second most common cause of death, first being the
cerebrovascular accident.[1] In developing countries, these
patients usually present very late with severe to complete
visual loss from optic atrophy.[12] About 50% of patients who
are diagnosed with primary brain tumors initially present with
ophthalmic signs and symptoms.[12,15]
The mean age of patients in this study was 43.17 years which is
comparable to 42.8 years seen in the study conducted by Snyder
Figure 2: Visual acuity at the time of presentation, number of patients,
and percentage
Figure 4: Visual field defects at the time of presentation
TNOA Journal of Ophthalmic Science and Research ¦ Volume 56 ¦ Issue 2 ¦ April-June 2018
et al.[16] The mean age in similar studies done in Iran and Kenya
were 33.9 and 37 years, respectively.[1,15] Thus, brain tumors
affect mainly young adults and middle‑aged individuals, the
economically and physically active subset of the society. In
children (age group 0–20 years), the prevalence was found to
be 5.8% which is similar to results seen by Mehrazin et al.[1]
I n o u r s t u d y, w e f o u n d t h a t t h e r e w a s f e m a l e
preponderance (11 females and 6 males) of brain tumors which
is in contrast to the study by Snyder et al.[16] (65 males and
36 females) and Onakpoya et al.[12] (53 males and 35 females).
Our study showed that majority of the patients were female,
that is, a clear sex predilection which is comparable with other
studies by Sefi-Yurdakul N.[17]
In this study, visual acuity of the worse eye was taken into account
for statistical purposes. At the time of presentation, most of the
patients had severe visual impairment. 70.58% (n = 12) of the
patients had a visual acuity 6/36 or less. Of these 12 patients,
3 patients denied perception of light in the worse eye. Kaur
et al. observed in their study that the degree of improvement
is inversely related to the duration of symptoms.[18]
The signs and symptoms seen in patients with a brain tumor
are a result of both local and generalized effects. Local effects
include direct pressure over the neural pathways, vascular
compromise, and abnormal nervous system stimulation
producing seizures. Involvement of the motor system produces
weakness. Tumors affecting the sensory area cause paraesthesia
or numbness. The patients presented with a wide variety
a b
Figure 3: (a) Symptoms at the time of presentation. (b) Signs at the time
of presentation
Figure 5: Types of brain tumor found in the study
73
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Deshmukh, et al.: Ophthalmic manifestations of brain tumors
of symptoms. Diminution of vision was the most common
ophthalmic symptom in this series, seen in all patients (100%).
These results are similar to previous reports, that is, 88.6%
and 86%. [10,11] Involvement of the vision is because of
mass‑compression effect on the optic nerve, the optic chiasma,
or the optic tract. Headache was the second most common
symptom observed in 41.17% of the patients for which they
sought the medical help. It is a common symptom manifesting
in about 43% to 99% of patients with brain tumor.[10,15,19] Other
symptoms reported were vertigo, vomiting, tinnitus, diplopia,
facial swelling, epistaxis, arthritis, pallor, and ptosis.
The most common ocular sign observed on fundus examination
was optic disc atrophy, seen in 47.05% of the patients. Onakpoya
et al. in their study found optic disc atrophy and papilledema
in 44.4% of the patients, which is in line with the results of our
study.[12] Optic disc pallor was seen in 29.41% and papilledema in
11.76% of the patients. Papilledema was reported in 27.7% and
46.8% of patients with intracranial tumors in studies conducted at
New York and Romania, respectively.[7,16] These findings highlight
the importance of ophthalmoscopy in neuro‑ophthalmology
examination in the patients with brain tumor. Tumors located
anteriorly have a higher tendency to cause optic nerve
compression which can be easily observed on ophthalmoscopic
examinations.[15] In our study, 2 (11.17%) patients had extraocular
movement restriction which is similar to study by Onakpoya
et  al.[12] Mass effect or infiltration by the tumor can affect
ocular nerves causing gaze restriction and diplopia. RAPD is an
important early sign of unilateral optic nerve compression that is
seen in almost half the patients with brain tumor. Similar to other
studies, the prevalence of RAPD in our study was 41.17%.[10,15]
Visual field defects arise as a result of disruption of the visual
pathway. Their pattern depends on the location of the tumor.
In our study, hemianopia was found to be the most common
visual defect, followed by quadrantopia. The hallmark field
defect seen in pituitary tumors is bitemporal hemianopia.[20]
The typical visual field defect, bitemporal hemianopia, is due
to the anatomical compression of the optic chiasma, which
contains the crossing nasal fibers of each optic nerve.[21] In our
study, similar findings were seen, five patients with pituitary
macroadenoma had bitemporal hemianopia. Trautman et al.
detected that visual fields are affected more often than visual
acuity.[22]
Meningioma was the most common tumor observed in this
study, with a prevalence of 41.17%. Onakpoya et  al. also
found meningiomas to be the most common brain tumor
with a prevalence of 36.4%.[12] The next most common
tumor encountered was pituitary macroadenoma followed by
craniopharyngioma and posterior fossa tumor. In contrast to
our study, Tagoe et al. found pituitary adenoma to be the most
common brain tumor with a prevalence of 55.5% followed by
meningioma 27.8%.[23]
Strengths and limitations
One of the limitations of our study is its retrospective nature.
Second, only data that have been recorded previously in
74 TNOA Journal of Ophthalmic Science and Research ¦ Volume 56 ¦ Issue 2 ¦ April-June 2018
medical records were available. There may have been other
signs and symptoms that were not recorded. Third, we only
analyzed the patients who were diagnosed to have a brain
tumor, and we did not analyze patients who had signs such as
optic nerve pallor or swelling that did not have brain lesions.
Moreover, follow‑up of the patients was not available, as to
what surgery the patient underwent and what the outcome was,
as after the MRI diagnosis they were referred to and managed
by outside facilities. However, despite these limitations,
we do define the profile of brain tumors and emphasize the
importance of a complete neuro-ophthalmological examination
to identify them.
Conclusions
Ocular features can be considered as a window through which
we can detect brain lesions. Early detection of a brain tumor
through ocular signs and symptoms can help in early diagnosis
and appropriate management. All the patients presenting with
diminution of vision and with fundus findings must undergo
visual field examination. MRI must be performed in doubtful
cases to delineate the exact anatomical location and diagnosis
of the lesion. Prognosis of the patients is much better if the
lesion is detected early and treated appropriately. Thus,
ophthalmologists play an important role in saving the life and
vision of these patients.
Acknowledgment
We would like to thank Sri Kanchi Sankara Health and
Educational Foundation, Guwahati, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Mehrazin M, Rahmat H, Yavari P. Epidemiology of primary intracranial
tumors in Iran, 1978‑2003. Asian Pac J Cancer Prev 2006;7:283‑8.
2. Jane JA Jr. Management of pediatric sellar tumors. Pediatr Endocrinol
Rev 2008;5 Suppl 2:720‑6.
3. Shamim  MS, Bari  ME, Khursheed  F, Jooma  R, Enam  SA. Pituitary
adenomas: Presentations and outcomes in a South Asian country. Can J
Neurol Sci 2008;35:198‑203.
4. Chanson P, Salenave S. Diagnosis and treatment of pituitary adenomas.
Minerva Endocrinol 2004;29:241‑75.
5. Sharma K, Pradhan S, Varma A, Rathi B. Irreversible blindness due to
multiple tuberculomas in the suprasellar cistern. J Neuroophthalmol
2003;23:211‑2.
6. Echevarría ME, Fangusaro  J, Goldman  S. Pediatric central nervous
system germ cell tumors: A review. Oncologist 2008;13:690‑9.
7. Neacşu E, Bogdănici C, Ianovici  N. Papillary edema in expansive
intra‑cranial tumors. Oftalmologia 2008;52:78‑83.
8. David  NJ. Pituitary apoplexy goes to the bar: Litigation for
delayed diagnosis, deficient vision, and death. J  Neuroophthalmol
2006;26:128‑33.
9. Kim  SH, Lee  KC, Kim  SH. Cranial nerve palsies accompanying
pituitary tumour. J Clin Neurosci 2007;14:1158‑62.
10. Masaya‑anon P, Lorpattanakasem J. Intracranial tumors affecting visual
system: 5‑year review in Prasat Neurological Institute. J  Med Assoc
Thai 2008;91:515‑9.
[Downloaded free from http://www.tnoajosr.com on Monday, August 6, 2018, IP: 10.232.74.23]

Deshmukh, et al.: Ophthalmic manifestations of brain tumors

11. Kitthaweesin  K, Ployprasith  C. Ocular manifestations of suprasellar
tumors. J Med Assoc Thai 2008;91:711‑5.
12. Onakpoya OH, Komolafe EO, Akintomide F, Ajite K, Komolafe MA,
Adeolu AA, et al. Ophthalmic manifestations in patients with intracranial
tumors. Afr J Neurol Sci 2009;28:55‑60.
13. Russell  DS, Rubenstein  LJ. Pathology of Tumors of the Nervous
System. Baltimore: Lippincott Williams and Wilkins; 1989. p. 120‑30.
14. Asai  A, Hoffman  HJ, Hendrick  EB, Humphreys  RP, Becker  LE.
Primary intracranial neoplasms in the first year of life. Childs Nerv Syst
1989;5:230‑3.
15. Marco  S, Karimurio  J, Kariuki  M, Lubanga  P. Visual loss and ocular
involvement in adult patients with intracranial neoplasms in Kenyatta
national hospital, Nairobi, Kenya. East Afr J Ophthalmol 2007;13:15‑20.
16. Snyder H, Robinson K, Shah D, Brennan R, Handrigan M. Signs and
symptoms of patients with brain tumors presenting to the emergency
department. J Emerg Med 1993;11:253‑8.
17. Sefi‑Yurdakul N. Visual findings as primary manifestations in patients
with intracranial tumors. Int J Ophthalmol 2015;8:800‑3.
18. Kaur A, Banerji  D, Kumar  D, Sharma  K. Visual status in suprasellar
pituitary tumours. Indian J Ophthalmol 1995;43:131‑4.
19. Gupta RK, Kumar R. Benign brain tumours and psychiatric morbidity:
A  5‑years retrospective data analysis. Aust N Z J Psychiatry
2004;38:316‑9.
20. Bynke  H. Pituitary adenomas and their ocular manifestations:
Incidence of cases and clinical findings, 1946‑1984. Neuroophthalmol
1986;6:303‑11.
21. Miller  NR, Newman  NJ, Biousse  V, Kerrison  JB. Walsh and Hoyt’s
Clinical Neuro‑Ophthalmology. 6th  ed. Philadelphia: Lippincott
Williams and Wilkins; 2005. p. 503‑73.
22. Trautmann JC, Laws ER Jr. Visual status after transsphenoidal surgery
at the Mayo clinic, 1971‑1982. Am J Ophthalmol 1983;96:200‑8.
23. Tagoe  NN, Essuman  VA, Fordjuor  G, Akpalu  J, Bankah  P, Ndanu  T,
et al. Neuro‑ophthalmic and clinical characteristics of brain tumours in
a tertiary hospital in Ghana. Ghana Med J 2015;49:181‑6.

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