1. Grand Rounds Conference
Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
2/20/15

2. 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.
Ptosis – progressive over several years, OD > OS. Holds lids up to see.

3. History POH: none PMH: none Eye Meds: none Meds: none FOH: Glaucoma
FH: Cancer, stroke

4. Objective OD OS VA: 20/20 20/25 Pupils: 4->2 4->2, no rAPD
IOP:
EOM: full OU
CVF: poor temporally OU
Levator function > 10 mm is excellent; < 5 is poor

5. Objective
PLE: E/L/L: WNL OU C/S: White, quiet OU K Clear OU AC Deep & quiet I/L WNL OU Vit WNL OU DFE: OD: ON c/d 0.4 with temp sloping, MVP WNL OS: ON c/d 0.4 sharp/pink, MVP WNL

6. GVF

7. MRI

8. MRI

9. MRI

10. Lab results
Prolactin, T3, T4, TSH, cortisol, LH, FSH, and IGF-1 all WNL

11. 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

12. Plan
Referral to neurosurgery with subsequent transseptal sphenoidotomy
Scheduled for post-op VF

13. Pituitary Adenoma Benign epithelial
Most common sellar mass, composing 10-15% of all intracranial tumors
Incidence is 1-7 cases per 100,000

14. Classification Size Activity Microadenoma: <10mm
Macroadenoma: >10mm
Activity
Functional (74%)
Non-functional (26%)
95% present as macroadenomas
2/3 of these patients have visual field defects

15. Presentation Functioning Non-functioning
Prolactinoma: amenorrhea, galactorrhea
Growth hormone: gigantism and/or acromegaly
ACTH: Cushing’s
TSH: weight loss, tachycardia, diarrhea
Non-functioning
Headache
VF defects

16. Treatment Observation Medical: Bromocryptine for prolactinomas Surgery
Radiotherapy
Sjogren and Hashimoto thyroiditis; HIV

17. 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

18. 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

19. References BCSC: Neuro-Ophthlamology. Pgs 146-151
Pituitary Tumors: adenoma, craniopharyngioma, cysts. Mayfield Clinic and Spine Institute. Feb 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: , 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