How does empty sella syndrome cause vision changes?

From the Guidelines

Empty sella syndrome can cause vision changes primarily through pressure effects on the optic chiasm and optic nerves, leading to various visual disturbances. This condition occurs when the pituitary gland appears flattened or shrunken within an enlarged sella turcica (the bony cavity that houses the pituitary gland) 1. As cerebrospinal fluid fills this space, increased pressure can compress nearby visual structures, particularly the optic chiasm which sits just above the pituitary gland. Some key points to consider in the diagnosis and management of empty sella syndrome include:

• The use of MRI as the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions 1
• The importance of characterizing lesions of the sella, suprasellar cistern, and any cavernous sinus invasion 1
• The role of MRI in confirming absence or ectopia of the posterior pituitary gland 1
• The potential for pituitary underdevelopment to be suggested on the basis of imaging 1 Key considerations in the management of empty sella syndrome include:
• Regular monitoring for mild cases
• Medication for managing intracranial pressure (such as acetazolamide)
• Surgical intervention to relieve pressure on the optic structures in severe cases The treatment approach should prioritize minimizing morbidity, mortality, and optimizing quality of life, with a focus on early detection and management of visual changes 1.

From the Research

Causes of Vision Changes in Empty Sella Syndrome

• Vision changes in empty sella syndrome can be caused by the downward prolapse of the optic chiasm into the sella turcica, which can compress the optic nerves and cause visual disturbances 2, 3.
• The herniation of the optic chiasm into the sellar cavity can be due to various factors, including compression by a tumor, mechanical injury during operation, or radiation effect 2.
• In some cases, the visual deterioration may not be directly related to the prolapse of the optic chiasm, and the exact mechanisms of visual improvement after chiasmapexy are not fully understood 3.
• The use of chiasmapexy, a surgical technique that involves elevating the optic chiasm, has been shown to be effective in improving visual function in patients with empty sella syndrome 3, 4.

Types of Empty Sella Syndrome

• Primary empty sella syndrome is a rare condition that can be caused by an abnormal dilatation of the optic recess, leading to a partial herniation of the optic chiasm into the sella turcica 5.
• Secondary empty sella syndrome can occur after medical or surgical treatment of a pituitary macroadenoma, or spontaneous hemorrhage into such a tumor 2, 3.
• Empty sella syndrome can also be a complication of decompression of a Rathke cleft cyst, leading to visual deterioration and herniation of the anterior cerebral artery 6.

Treatment Options

• Chiasmapexy is a surgical technique that involves elevating the optic chiasm to treat empty sella syndrome, and has been shown to be effective in improving visual function 3, 4.
• The use of autologous cartilage and bone as materials for chiasmapexy has been described as a minimally invasive and effective option 4.
• Transnasal packing of the sellar floor with fat graft and bone plaques has also been used to treat empty sella syndrome and improve visual function 6.