Surgical Timing in Relation to Visual Dysfunction in Skull Base Meningiomas Involving the Anterior Visual Pathway: A Propensity Score-Matched Analysis

Background/Objectives: Observation is generally recommended for asymptomatic meningiomas, but evidence from incidental meningiomas is derived largely from heterogeneous intracranial locations and may not directly apply to tumors involving the anterior visual pathway. We investigated whether preoperative visual status remained associated with postoperative visual function after adjustment for baseline clinical and anatomical differences in this location-specific subgroup. Methods: We retrospectively reviewed 146 patients who underwent resection of skull base meningiomas contacting or compressing the optic nerve and/or chiasm. Preoperative visual status was categorized by comprehensive ophthalmologic evaluation as normal visual function or visual dysfunction. The primary outcome was postoperative normal visual function, defined as preservation of normal vision in patients with normal preoperative visual function and complete recovery in those with preoperative visual dysfunction. Multivariable logistic regression was performed, and propensity score matching was conducted using age, sex, tumor volume, tumor laterality, and optic canal involvement. Results: Propensity score matching yielded 48 matched pairs with adequate balance across all measured covariates (all standardized mean differences < 0.1). Postoperative normal visual function was preserved or achieved in 95.8% of patients with normal preoperative visual function versus 31.3% of those with preoperative visual dysfunction (exact McNemar p < 0.001). Favorable visual outcome occurred in 95.8% versus 77.1%, respectively (p = 0.0225). Conclusions: Among surgically treated patients, normal preoperative visual function remained strongly associated with postoperative normal visual function after adjustment for measured clinical and anatomical differences. These findings do not establish that earlier surgery improves visual outcomes or define an optimal surgical timing strategy, but suggest that preoperative visual status and tumor anatomy should be considered in individualized management decisions.