Grand Rounds Conference

Eric Downing MDUniversity of Louisville

Department of Ophthalmology and Visual Sciences

2/20/15

Subjective CC/HPI: 35 year old male with

complaint of progressive decreased peripheral vision x 6 months. No flashes/floaters or blurry vision.

Review of Systems: denies dizziness, weakness, numbness, or headaches.

History

POH: nonePMH: noneEye Meds: noneMeds: none

Objective

OD OSVA: 20/20 20/25Pupils: 4->2 4->2,

no rAPDIOP: 13 13EOM: full OU

CVF: poor temporally OU

ObjectivePLE: E/L/L: WNL OUC/S: White, quiet OUK Clear OUAC Deep & quietI/L WNL OUVit WNL OUDFE:OD: ON c/d 0.4 with temp sloping, MVP WNLOS: ON c/d 0.4 sharp/pink, MVP WNL

GVF

MRI

MRI

MRI

Lab results

Prolactin, T3, T4, TSH, cortisol, LH, FSH, and IGF-1 all WNL

Assessment

35 year old male with painless progressive temporal vision loss for 6 months, bitemporal hemianopsia, and an MRI which revealed a pituitary mass.

Dx: Pituitary Macroadenoma

Plan

Referral to neurosurgery with subsequent transseptal sphenoidotomy

Scheduled for post-op VF

Pituitary Adenoma

Benign epithelial Most common sellar

mass, composing 10-15% of all intracranial tumors

Incidence is 1-7 cases per 100,000

Classification

Size Microadenoma: <10mm Macroadenoma: >10mm

Activity Functional (74%) Non-functional (26%)

95% present as macroadenomas 2/3 of these patients have visual field

defects

Presentation

Functioning Prolactinoma: amenorrhea,

galactorrhea Growth hormone: gigantism and/or

acromegaly ACTH: Cushing’s TSH: weight loss, tachycardia, diarrhea

Non-functioning Headache VF defects

Treatment

Observation Medical: Bromocryptine for

prolactinomas Surgery Radiotherapy

Associated Syndromes

Multiple Endocrine Neoplasia Type 1 Pituitary Adenomas (prolactinomas) Parathyroid Pancreatic Islet cell tumor

Pituitary Apoplexy Infarction of a pituitary tumor or

sudden hemorrhage within Sudden onset of HA, vision loss,

diplopia, and/or ptosis

Research

Investigated the degree of residual VF impairment with size of adenoma

Retrospective analysis Divided groups based on vertical

tumor size Created a Visual Impairment Score

(VIS) VA and VF defect parameters

Results: tumors greater than 20mm result in persistent vision deficits, and should undergo surgical resection

References BCSC: Neuro-Ophthlamology. Pgs 146-151 Pituitary Tumors: adenoma, craniopharyngioma,

cysts. Mayfield Clinic and Spine Institute. Feb 2013. pgs 1-6

Ferrante E, Ferraroni M, Castrignano T, Menicatti L, Anagni M, Reimondo G, et al. Non-functioning pituitary adenoma database: a useful resource to improve clinical management of pituitary adenomas. Eur J Endocrinol 155: 823-829, 2006.

The influence of pituitary adenoma size on vision and visual outcomes after trans-sphenoidal adenectomy: a report of 78 cases. Ren-Wan H, Hsiu-Mei H, Jih-Tsun H. J Korean Neurosug Soc 57(1): 23-31, 2015