2026 Proffered Presentations
S045: VISUAL FIELD RECOVERY PATTERNS FOLLOWING ENDOSCOPIC TRANSSPHENOIDAL SURGERY FOR PITUITARY MACROADENOMAS: A SINGLE-ARM META-ANALYSIS
Khushal Gupta, MBBS1; Michael Karsy, MD, PhD, MSc, FAANS, FCNS2; 1Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Medical College; 2University of Michigan Health
Introduction: Visual loss is the most disabling consequence of pituitary macroadenomas, often driven by compression of the optic chiasm. Endoscopic transsphenoidal surgery has become the standard approach, but reported outcomes vary widely. In particular, the likelihood of visual recovery, complete normalization, or postoperative deterioration, as well as risks such as cerebrospinal fluid (CSF) leak, remain uncertain. We performed a meta-analysis to evaluate visual field outcomes following endoscopic resection of pituitary macroadenomas.
Methods: We systematically searched PubMed, Embase, and Scopus in accordance with PRISMA guidelines to identify studies through 2024 that reported postoperative visual field outcomes after endoscopic endonasal surgery. Only studies reporting pituitary macroadenomas were included. While most series reflected elective resections for symptomatic chiasmal compression, heterogeneity may reflect differences in tumor size and acuity of presentation. Case reports and very small series (<5 patients) were excluded. Two reviewers extracted study characteristics, patient numbers, follow-up, and outcomes including visual field improvement, normalization, worsening, and CSF leak. Pooled analyses were performed using a random-effects model with inverse variance weighting and Freeman–Tukey double arcsine transformation. Between-study heterogeneity was quantified using the I² statistic, and prediction intervals were calculated to reflect the range of outcomes expected in future studies.
Results: Across 27 studies including 2,012 patients, the pooled rate of visual field improvement was 77% (95% CI: 72–83%), underscoring that the majority of patients experience meaningful recovery. In 12 studies with 1,229 patients, complete visual field normalization was achieved in 42% (95% CI: 30–54%), though outcomes are likely influenced by baseline severity of visual dysfunction, which was variably reported across studies. This highlights that while many patients recover, only a subset regain entirely normal fields. Conversely, visual worsening was exceedingly rare, affecting just 1% of patients (95% CI: 0–2%) across 20 studies (1,516 patients), with generally consistent findings across cohorts, though the low event rate and modest sample sizes may partly explain the low heterogeneity. With respect to surgical safety, 20 studies including 2,591 patients reported a pooled CSF leak rate of 8% (95% CI: 5–11%), making it the most frequent postoperative complication. Considerable heterogeneity across studies likely reflects differences in surgical technique, tumor size, and definitions of leak.
Conclusion: This meta-analysis shows that endoscopic transsphenoidal surgery for pituitary macroadenomas leads to substantial visual recovery in most patients, with nearly half regaining normal visual fields and very few suffering deterioration. CSF leak remains the most frequent complication, though the primary finding is one of durable and meaningful visual improvement. Taken together, these findings reinforce the effectiveness and overall safety of the endoscopic approach, while also emphasizing the need for standardized outcome reporting and prospective multicenter studies to refine benchmarks for surgical quality.
