This document describes a case of a 56-year-old female presenting with gradual vision loss in her left eye over several months. Her medical history includes hypertension and hypercholesterolemia. Examination found decreased vision in the left eye, a constricted visual field in that eye, and an abnormal field in the right eye. MRI revealed a large heterogeneous enhancing sellar mass compressing the optic chiasm, consistent with a pituitary adenoma. The patient was referred for urgent evaluation by neurosurgery and neuroimaging given the risk of further vision loss from the tumor.

1. Indescribable
Vision Loss
Noushin S. Ahmed, O.D.
Ocular Disease Resident
Seidenberg Protzko Eye Associates

2. Chief Complaint
› 56
yo Caucasian female presents as a
new patient complaining about
decreased vision in the left eye
› She states it has been worsening gradually
over the past few months.
› She claims reading has become more
difficult and computer work has been
tougher.
› LEE 2 months ago

3. Ocular History
› Traumatic
penetrating injury OD 1975
› Cataract
surgery OD with BCVA 20/40 2012
› Iris reconstruction 2012

4. Medical History
› Hypertension
› Treated
with Lisinopril 20mg qd po
› Hypercholesterolemia
› Treated
› Hayfever
with Lipitor 20mg qd po

5. Family History
› Unremarkable
Social History
› Former
smoker x 10 years
› denies
alcohol & recreational drug use

6. External Examination
BCVA
OD 20/40
OS 20/50
Pupils
OD Surgical
OS PRRL(+)APD
CVF
OD temporal abnormal field
OS constricted field
EOM
FROM OU
(-)pain, (-) diplopia
Adnexa
Normal OU

7. Biomicroscopy
Conjunctiva
white & quiet OU
Cornea
Clear OU
Iris
OD post-surgical w/suture @ 8 oclock
OS normal
AC
deep and quiet OU
Lens
OD PCIOL in good position, tr PC haze
OS NS 2+
IOP
16mm Hg OU

8. Additional Tests
› Ishihara
OD 5/7
OS 5/7
› Red
Cap Test
OS desaturated
› Subjective
Brightness
OS decreased

9. HVF 24-2

10. Fundus Examination
OD
OS
Vitreous
clear
Asteroid hyalosis
Optic nerve
Flat, sharp, good
color
Flat, sharp, good
color
CD Ratio
0.2v/0.2h
0.25v/0.25h
Macula
Rare drusen
Rare drusen
Vessels
2/3 AV ratio
2/3 AV ratio
Periphery
(-) holes, tears,
detachments
(-) holes, tears,
detachments

11. Differential Diagnoses
› Sellar/suprasellar
mass
› Pituitary
Adenoma
70%
› Craniopharyngiomas 12.8%
› Meningioma
10.6%
› Gliomas
3.9%
› Germinomas
› Sarcoidosis
› Lymphocytic
infiltration
› “Delayed” indirect optic nerve chiasm
injury

12. Assessment
1.
2.
3.
4.
5.
Homonymous
Hemianopsia,
Bilateral
Crystal Deposit,
OS
Cataract,
Incipient OS
Pupillary
abnormalities, OD
After cataract
obsucration, OD
Plan
1.
2.
3.
4.
5.
Urgent Evaluation
w/neurosurgery
and neuroimaging
Not clinically
significant
Incipient—not
cause of visual loss
H/o successful iris
sutures
Progressing PC
haze

13. MRI Results
› Large
Heterogenous
enhancing sellar
mass
› 2.5 x 2.2 x 3.2 cm
› Cystic necrosis
› ICA – normal flow
› Cavernous sinuses –
unfiltrated
› Compresses optic
chiasm
http://neurosurgery.ucla.edu/images/Pituitary%20Program/NonFunction_MRI.jpg

14. Pituitary Adenoma
› Funtional
› Non-functional
› Pre-fixed
› Post-fixed
› Hardy
Wilson
Classification system1
› Stage
0
› Stage A
› Stage B
› Stage C

15. Systemic Symptoms
› Headache
› Amenorrhea
› Galactorrhea
› Impotence
› Fatigue
http://2.bp.blogspot.com/-RC9sou7utqE/UYuh1YfpZDI/AAAAAAAAAMQ/l7rZRIPuMbk/s1600/Migraine%2BII.jpg

17. Visual Complaints
› Decreased
vision
› Loss of depth perception
› Difficulties with near tasks
› Diplopia
› Photophobia
› Dyschromatopsia

18. Visual Loss Determinants
› Tumor
size
› Growth direction
› Rate of Growth
› Individual anatomy

19. Visual Symptoms
› Cavernous
› Chiasm
VF defect
› Intermittent diplopia
› Seesaw nystagmus
›
› CN
sinus
III
› Upgaze
› Downgaze
› Medial
› 3rd
›
Ventricle
Hydrocephalus
› Upgaze
› Light-near
diss
Convergenceretraction
Nystagmus
› Papilledema
›
gaze
› Diplopia
› Ptosis
› Mydriasis
› CN
IV & VI
› LR
› CN
& SO palsies
V1
› Loss
of sensation

20. Visual Pathway

21. http://www.medicinemcq.com/index.php/journals/sub_details/138/39/FMGE-MARCH-2012-ENT-AND-OPHTHALMOLOGY

22. VF Defect & Pituitary Adenoma

23. VF Defect & Pituitary Adenoma

24. VF Defect & Pituitary Adenoma

25. Fundus Findings
Temporal Pallor
Band/Bowtie Atrophy
Optic Atrophy
Papilledema
http://ophthalmology.stanford.edu/blog/archives/2009/10/bowtie-optic-at.html

26. Pituitary Apoplexy
› Infarction
› Hemorrhage
› Necrosis
› Systemic
Symptoms
Headache
› Altered state
› Nausea/vomiting
› Stiff neck
› Endocrine
Dysfunction
› Parasthesia
› Seizures
›
› Visual
Symptoms
› Visual
blurring
› VF defects
› Diplopia
› Ophthalmoplegia
› Dorsal Midbrain
syndrome
› Photophobia

27. Treatment
› Goals
› Control
growth
› Normalize function
› Preserve/restore
vision
› Surgery
› Medical
Therapy
› Radiotherapy
› Expectant
Observation

28. Prognosis
› Surgery
VA 46.5 – 79%
› VF 70 – 90%
›
› Radiotherapy
VF 16 – 78%
› GKS
›
› 53%
CN
› 20% major
improvement
› 30% dec tumor
volume
› Bromocriptine
› Improved
visual
function
› VF improved

29. Risks of Treatment
› Surgical
› Direct
Removal
injury/
devascularization
of optic apparatus
› Prolapse into
empty sella
› Orbital Fracture
› Hematoma
› Cerebral
vasospasm
› Bromocriptine
› Visual
hallucinations
› Tumor reexpansion
› Chiasmal
herniation

30. Risks of Treatment
› Chiasmopathy
› Delayed
radionecrosis of
CNS
› 0.25 – 25%2
› Radiation
Optic neuropathy
› Acute, unilateral loss of
vision
› Central scotoma/arc
defects
› Bitemporal hemi
› ON initially normal à
pale
› MRI: enlargement of
enhancement of CNS/
chiasmal tract
http://www.healio.com/~/media/Journals/OSLI/2012/1_January/10_3928_15428877_20111129_09/fig4.ashx

31. Risk Factors
› Macroadenoma
› Previous
Visual
Impairment
› Bottleneck/dumbbell shaped tumor
› Previous surgery
› Lumbar
subarachnoid
catheter
http://www.neurologyindia.com/viewimage.asp?img=ni_2013_61_2_122_111114_f5.jpg

32. Predictors of Visual Outcome
› >
20/100 pre-op: improvement
› < 20/100 pre-op: normalized
› Duration of visual complaints
› Previous surgery
› Age <69
› No frank Optic Atrophy
› Tumor Size
› Normal Color
› (-) APD

33. VF Improvement
1.
2.
3.
Early Fast Phase: days – 1 week
Slow Recovery Phase: weeks – 2 months
Late Phase: months – years
**improvement: as long as 5 years post-op

34. Post-op management
› Multidisciplinary
approach
› Baseline
› VA
› Color
› Motility
› VF
Exam
› Post-op
› 2-3
months
› 6-12 months

35. Conclusion
› Multidisciplinary
› Patients’
varying symptoms and status
› Understanding VF, afferent visual
pathway, anatomy and CN exam

36. References
1.
2.
3.
4.
5.
6.
7.
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Chhabra, Vaninder S., MD, and Nancy J. Newman, MD. "The Neuro-Ophthalmology
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Chiu, Eric K., and Jeffrey W. Nichols. "Sellar Lesions and Visual Loss: Key Concepts in
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Chung, Sophia M., MD. "Neuro-ophthalmic Manifestations of Pituitary Tumors." NeuroOphthalmology for Neurosurgeons 10.4 (1999): 717-29. Print.
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37. References cont.
8.
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13.
14.
Fu, Xiangping, and Hongqi Wang. "Ocular Symptoms of Tumors at Sella Turcica Region."
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Gedik, Sansal, MD, Sirel Gur, MD, Basar Ataly, MD, Meric Colak, Nur Altinors, MD, and
Yonca A. Akova, MD. "Humphrey Visual Field Analysis, Visual Field Defects, and
Ophthalmic Findings in Patients with Macro Pituitary Adenoma." Saudi Medical Journal
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Kedar, Sachin, Deepta Ghate, and Jamesj Corbett. "Visual Fields in Neuroophthalmology." Indian Journal of Ophthalmology 59.2 (2011): 103. Print.
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