Suprasellar meningioma presenting with glaucomatous type cupping

Abstract

Purpose: To describe a case of a suprasellar meningioma compressing the chiasm from below and producing a unilateral fascicular (nasal) visual field defect that mimicked glaucomatous cupping. Case report: A 78-year-old man presented with painless, progressive, unilateral arcuate visual field defect. He was diagnosed with “normal tension glaucoma” based on an asymmetric cup to disc ratio. Despite treatment with anti-glaucoma drops, the visual field defect progressed. Neurophthalmic evaluation was consistent with a compressive optic neuropathy OD. Brain MRI showed a suprasellar meningioma compressing on the junction of the optic nerve and chiasm from below. Conclusion: Although junctional visual field loss (e.g. junctional scotoma and junctional scotoma of Traquair) are well-known presentations of compressive lesions at the optic chiasm, we describe a monocular, ipsilateral compressive superior nasal defect and asymmetric cupping as the presenting sign of a junctional compressive lesion mimicking glaucomatous cupping.

Clinical Reasoning: Wilbrand’s Knee, Scotoma of Traquair, and Normal Tension Glaucoma

“…In these cases, the clinician may inadvertently miss a compressive intracranial cause and focus attention on an intraocular cause of field defect. Interestingly, an expanding mass in the sellar region may asymmetrically compress the chiasm or compress the distal optic nerve(s) before the chiasm producing a true monocular visual field defect with a fascicular defect [ 11 , 12 ]. To add confusion in the clinical evaluation of these cases, one has to consider that in compressive optic neuropathy, the optic nerve may appear normal initially.…”

“…In fact, visual function (color and acuity) is usually preserved in glaucoma until later stages because of the relative sparing of the papillomacular bundle [ 15 , 16 ]. However, even in compressive optic neuropathy, visual acuity may be normal initially [ 11 ]. The clinician may thus face the case of a fascicular monocular visual field defect with normal visual acuity and an unremarkable (or cupped) optic disc with not so much pallor, and easily led to diagnose an NTG.…”

Glaucomatous Type Cupping Caused by Internal Carotid Artery Compression: a Case Report

“…Thus, compression of the intracranial optic nerve up to the junction of the anterior optic chiasm can produce accurate visual field defects resembling glaucoma with sparing of central vision. 12…”

“…Thus, compression of the intracranial optic nerve up to the junction of the anterior optic chiasm can produce accurate visual field defects resembling glaucoma with sparing of central vision. 12 Clinicians should be aware of these distinguishing and differentiating features of non-glaucomatous optic neuropathy and consider neuroimaging to exclude a compressive lesion mimicking glaucoma.…”

Neuro-Ophthalmological Optic Nerve Cupping: An Overview

“…Compressive optic neuropathies causing cupping have been observed in patients with pituitary adenomas, 6 , 7 , 16–20 aneurysms, 21–24 craniopharyngiomas 19 , 25 and meningiomas. 16 , 17 , 19 , 26 , 27 Bianchi-Marzoli et al 28 performed a masked measurement of the optic discs of 29 patients with compressive optic neuropathies and 20 age-matched controls. This study found a significantly larger cup-to-disc ratio (0.37) for eyes with compressive optic neuropathies than for control eyes (0.10).…”