Meningiomas located in the anterior and middle cranial fossae can exert pressure on the optic nerve (ON), resulting in varying degrees of visual impairment. The optic nerve is anatomically divided into three segments—intraorbital, intracanalicular, and intracranial—each of which influences the severity and pattern of compression. Intracranial meningiomas, particularly those arising in regions such as the olfactory groove or anterior clinoid process, may affect both the optic nerve and the optic chiasm, leading to a spectrum of symptoms that vary according to the specific tumor location and the anatomical configuration of the chiasm (1, 2).

Early manifestations of visual impairment are frequently observed in cases with prefixed chiasms, where the optic nerve is in closer proximity to the tumor, while patients with postfixed chiasms tend to exhibit a delayed onset of symptoms (3, 4). Diagnostic challenges arise from the complex anatomy of the intracranial space and orbit, areas that lack the dense supportive tissues found elsewhere, thereby complicating early detection. In contrast, meningiomas that extend into the optic canal (OC) often produce symptoms earlier in the disease course, prompting more rapid clinical evaluation. A detailed understanding of the optic nerve’s anatomical relationships with surrounding structures is therefore crucial for enhancing diagnostic accuracy and assessing visual risks based on tumor location (3, 5, 6).

Management strategies for these patients range from observation and radiation therapy to surgical excision, with the overarching goal of preserving or improving visual function (7). The surgical approach, particularly decompression of the optic canal via procedures such as unroofing, remains a subject of debate due to the inherent risks and the variable outcomes reported in the literature (8). For patients with smaller tumors or minimal visual impairment, conservative management through observation is often considered safe. In cases where more aggressive treatment is warranted, radiation therapy may serve as a less invasive alternative to surgery, particularly for tumors situated near critical brain structures (9, 10).

This study is designed to elucidate the influence of surgical interventions on visual outcomes in patients with optic nerve–compressing meningiomas. By analyzing a range of ophthalmic, imaging, and surgical predictors, we aim to identify key factors that correlate with improved prognosis. Our goal is to optimize treatment strategies to better preserve or restore vision in this patient population.

The medical records from the Neurosurgical Clinic at Olomouc University Hospital were retrospectively reviewed to identify patients who underwent surgical treatment for meningiomas located near the optic nerve between 2015 and 2023. Inclusion criteria were limited to patients who had surgery at our clinic and had high-quality preoperative and postoperative MRI scans, along with complete ophthalmic records both before and after surgery. On MRI, optic nerve compression was verified by evaluating signs such as narrowing of the nerve, increased T2 signal intensity within the nerve, or other structural changes indicative of compression. All included patients had a minimum follow-up period of one-year post-surgery, with visual function assessments conducted at the Ophthalmology Clinic of University Hospital Olomouc.

Data collected from this cohort included demographic information, preoperative tumor characteristics such as tumor size, origin, its interaction with the optic nerve or optic chiasm. Additional variables considered included preoperative and postoperative measures of visual acuity and visual fields. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of University Palacky, Olomouc.

In total, 79 patients met the inclusion criteria for the study, consisting of 66 females and 13 males, with a mean age of 58 years. Tumor size was categorized into three groups by the maximum diameter in cm: (1) small tumors, under 3 cm; (2) medium tumors, ranging from 3 to 5 cm and (3) large tumors, over 5 cm. Based on the tumor’s relationship with the optic nerve or chiasm, the cohort was divided into four groups: (1) intimate contact with the optic nerve or chiasm, (2) compression of the optic nerve or chiasm, (3) dislocation of the optic nerve, and (4) encasement of the optic nerve within the tumor mass.

Tumor origin was classified into four categories: (1) planum sphenoidale meningiomas, (2) anterior clinoid meningiomas, (3) sphenoorbital meningiomas, and (4) cavernous sinus meningiomas. Meningiomas were categorized based on their primary site of origin and anatomical extension. For instance, if the tumor predominantly extended to the planum sphenoidale, it was classified under that group, while those extending primarily toward the anterior clinoid were included in the anterior clinoid category. The surgical approach varied depending on the tumor type and its anatomical relationship with surrounding structures, which likely influenced surgical outcomes and postoperative recovery.

Visual acuity and visual field assessments were recorded preoperatively, with patients categorized into three groups based on their visual status: (1) intact vision, (2) impaired vision, and (3) blindness. The term “visual status” encompasses both visual acuity and visual field deficits, as both aspects significantly impact quality of life in this disease. Postoperative visual outcomes were divided into four categories: (1) intact vision, (2) stable vision, (3) improved vision, and (4) worsened vision. These categories consider both visual acuity and visual field outcomes, as field deficits are common in this disease and significantly impact quality of life.

Statistical analysis was performed by a statistician. Categorical variables were compared using the chi-square test or Fisher’s exact test when appropriate. Continuous variables were assessed for normality, and comparisons between groups were made using either the ANOVA or Kruskal–Wallis test based on distribution. A receiver operating characteristic (ROC) curve was constructed to evaluate the relationship between symptom duration and postoperative visual outcome. A p-value < 0.05 was considered statistically significant.

This study offers valuable insights into the impact of meningiomas that compress the optic nerve (ON) on visual function, focusing on key factors such as tumor size, location, and the duration of preoperative visual impairment. The analysis highlights several critical trends in these variables, although some did not reach statistical significance, suggesting the need for further research and refinement of predictive models.

One of the notable trends observed in the data is the potential correlation between tumor size and the duration of vision impairment. Although this relationship did not achieve statistical significance, the data suggest that as tumor size increases, the duration of visual impairment may also tend to increase. This trend is consistent with the understanding that larger tumors often exert more pressure on the optic nerve, leading to a higher likelihood of progressive optic neuropathy. Larger tumors may cause more extensive and long-term damage to the optic nerve fibers, thus resulting in prolonged vision loss (11, 12).

These findings reinforce the clinical importance of early detection and intervention in patients with meningiomas near the optic nerve. Early identification of tumors, particularly larger ones, is crucial in preventing irreversible visual damage. Timely surgical or therapeutic interventions could potentially limit the extent of optic nerve compression and reduce the risk of severe or permanent vision loss. Furthermore, these results suggest that careful monitoring of tumor growth and visual function should be a priority for clinicians managing patients with meningiomas, particularly in cases where larger tumors are present or where vision impairment is already evident at the time of diagnosis (13, 14).

Interestingly, tumor location itself did not statistically impact preoperative or postoperative visual function, despite the known anatomical variations in optic nerve compression across different intracranial locations. This lack of correlation is notable, as one might expect certain tumor locations to have a more pronounced effect on visual function due to their proximity to critical structures like the optic nerve and optic chiasm. Several factors may explain this finding, including the relatively small sample size, the heterogeneity of tumor characteristics within each location group, or the complex nature of optic nerve compression, which involves multiple variables beyond just tumor location (15, 16).

This observation highlights the need for larger-scale studies with more comprehensive data to better understand the location-specific effects of meningiomas on visual outcomes (9). Larger cohorts may provide more robust insights into how different anatomical locations influence the severity and progression of visual impairment, allowing for more accurate predictions and improved management strategies for patients with meningiomas near the optic nerve (17).

The study revealed that the duration of preoperative visual impairment significantly correlated with the severity of visual function, with prolonged impairment being associated with worsened vision preoperatively. This finding supports existing research and emphasizes that the timing of symptom onset plays a crucial role in predicting visual outcomes (18). Patients who experienced shorter durations of vision loss (less than 8.5 months) tended to have better postoperative recovery, suggesting that surgical intervention may be most effective when performed shortly after the onset of visual symptoms.

Clinically, this 8.5-month threshold may help guide decisions on the timing of surgical intervention, especially in patients presenting with early or borderline symptoms. While the ROC analysis showed excellent sensitivity (1.0), its moderate specificity (0.692) indicates a risk of overtreatment in some cases. However, this trade-off may be acceptable when weighed against the potential for irreversible visual loss associated with delayed surgery. As such, this finding supports the clinical prioritization of timely intervention in patients with progressive optic nerve compression.

These findings suggest that earlier detection and intervention may be beneficial, although larger, prospective studies are needed to confirm these associations This could potentially inform future guidelines for treatment timing in patients with meningiomas that compress the optic nerve (ON) (19).

Interestingly, postoperative visual outcomes did not correlate with tumor size, location, or the duration of preoperative symptoms, which underscores the complexity of predicting visual recovery in this patient population (20). While factors such as tumor size and location intuitively seem to impact visual outcomes, the lack of a direct correlation in this study suggests that other variables, such as the extent of optic nerve damage, surgical technique, or individual patient factors, may play a more prominent role. However, a trend was observed indicating that shorter preoperative impairment durations may increase the likelihood of postoperative improvement. This suggests that early surgical intervention could improve the chances of visual recovery, further emphasizing the importance of timely treatment.

These findings highlight the multifactorial nature of visual outcomes following surgery for ON-compressing meningiomas and suggest that prompt surgical intervention remains a key factor in optimizing prognosis for patients with optic nerve involvement. Future studies with larger patient cohorts and more detailed assessments could help clarify the complex interplay of variables that influence visual recovery and help refine strategies for the management of these tumors (20, 21).

Our findings underscore the importance of tumor size and, particularly, the duration of preoperative vision loss as key factors influencing visual outcomes in patients with optic nerve-compressing meningiomas. While not all observed trends reached statistical significance, this study offers valuable insights into the complex interplay of variables that contribute to visual recovery. Our findings suggest that the duration of vision loss prior to surgery may be an important factor in visual prognosis, warranting further study to determine whether earlier intervention improves outcomes. Although some factors, such as tumor size and location, did not show a direct correlation with visual recovery, their potential role in conjunction with other variables warrants further investigation.

This study provides a foundation for understanding the factors associated with visual recovery and offers direction for future research aimed at refining prognostic models for patients with optic nerve compression due to meningiomas. Given the complexity of visual outcomes, future studies with larger sample sizes and more detailed subgroup analyses will be crucial to confirm these associations and to better predict which patients are most likely to benefit from surgical intervention. Additionally, these findings may help guide the development of more tailored therapeutic strategies, optimizing the timing of surgery and other interventions to preserve or improve vision in affected patients.

Further research, particularly with multicentre studies, could provide more robust evidence, helping clinicians make more informed decisions and improving patient care by refining the parameters that influence visual outcomes in this patient population.

Prior studies have shown that optic nerve compression by meningiomas leads to progressive visual loss, with factors such as tumor size, location, and duration of preoperative impairment thought to influence outcomes. However, the precise predictors of visual recovery remain unclear.

This study demonstrates that the duration of preoperative visual impairment is a critical determinant of postoperative visual recovery, with shorter impairment durations correlating with better outcomes. Notably, tumor size and location did not significantly impact recovery, underscoring the importance of early intervention.

These findings support the need for prompt diagnosis and early surgical management in patients with optic nerve–compressing meningiomas, potentially informing clinical guidelines and future research aimed at refining prognostic models for visual outcomes.