Grand Rounds Conference

Tala Kassm DOAugust 21st, 2015

University of LouisvilleDepartment of Ophthalmology and

Visual Sciences

Subjective CC: “My side vision is worse.”

HPI: 67 year old white male complains of progressive decreased peripheral vision OU over 3-4 months. He denies flashes, floaters, scotoma or eye pain.

Review of Systems: positive for headaches, general fatigue, increased fluid intake, aches and pains. Negative for weight loss or sexual dysfunction.

History

POH: none

PMH: hypertension, COPD

Family Hx: noncontributory

Meds: Albuterol, amlodipine, metoprolol

Allergies: azithromycin, niacin, clindamycin

Clinical Exam

OD OS

VA(cc,D): 20/20 20/25(plano +3.25x178)

(+1.75+1.00x170)

Pupils: 4->2 no rAPD 4->2

IOP: 13 17EOM: FULL FULL

CVF: bilateral temporal defect, worse OD than OS

Clinical Exam

SLE: OD OSExternal/Lids WNL WNLConj/Sclera white & quiet white & quietCornea clear clear Ant Chamber deep & quiet deep & quietIris WNL WNLLens 1-2+ NS 1-2+ NSVitreous Clear Clear

Clinical Exam

Dilated Fundus Exam:

OD: ON c/d 0.4, pink and sharp M/V/P: WNL

OS: ON c/d 0.5, pink and sharp M/V/P: WNL

HVF 24-2 OS

HVF 24-2 OD

HVF 24-2 OU

MRIMRIT1

Sagittal

MRIMRIT1

Transverse

MRIT2

Transverse

Lab results

Prolactin T3, T4, TSH Cortisol, ACTH stimulation test LH, FSH Serum osmolarity Testosterone and IGF-1 all within

normal limits

Assessment 67 year old male with progressive

temporal vision loss over 3-4 months. MRI revealed a pituitary mass.

Diagnosis: Nonsecreting Pituitary Macroadenoma

Differential includes: meningioma, craniopharyngioma, internal carotid artery aneurysm

Plan

Given that the tumor is non secreting, medical management with bromocriptine was thought to be ineffective.

Patient was referred to neurosurgery for endonasal endoscopic tumor resection.

Surgery date pending.

Pituitary Adenoma

Benign epithelial tumor Most common sellar mass,

composing 10-15% of all intracranial tumors

Incidence is 1-7 cases per 100,000 Rare in childhood Age-linked – increase with each

decade By 80th decade, small adenomas

found in more than 20% of pituitary glands

Classification

Size Microadenoma: <1cm Macroadenoma: >1cm

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

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

defects

Presentation

Functioning Lactotroph (Prolactin): amenorrhea,

galactorrhea Somatotroph (Growth hormone):

gigantism and/or acromegaly Corticotroph (ACTH): Cushing’s

syndrome Thyrotroph (TSH): weight loss,

tachycardia, diarrhea Non-functioning

Headache VF defects

Presentation

Impaired vision is the most common symptom that leads a patient with a nonfunctioning adenoma, to seek medical attention.

Due to suprasellar extension of the adenoma, leading to compression of optic chiasm.

Leads to bitemporal hemianopsia Diminished visual acuity with more

severe optic chiasm compression

Anatomy

Treatment

Observation Medical: Bromocriptine for

prolactinomas Surgery: transfrontal or

transsphenoidal approach Radiotherapy

Post Treatment

Vision recovery rapid after surgical resection of tumor, even with severe vision loss Onset of improvement within 24 hours

Slower improvement with medical management of tumor

Prognosis is poor if retinal nerve fiber layer thickness is less than 75 microns, by OCT scan

First sign of recurrence may be vision loss

Associated Syndromes

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

Pituitary Apoplexy Acute hemorrhage or infarction of a

pituitary tumor Potentially life threatening Sudden onset of severe headache,

nausea, altered consciousness, vision loss, diplopia, and/or ptosis

Other causes of parasellar tumor

Meningiomas Middle-aged women Often produce asymmetric bitemporal

vision loss Craniopharyngiomas

Common in children but may present at any age

Second incidence peak in adulthood Arise superiorly, produce inferior

bitemporal visual field loss Internal carotid artery aneurysms

(supraclinoid region) Markedly asymmetric chiasmal syndrome Optic nerve compression on side of

aneurysm

The time course of visual field recovery and changes of retinal

ganglion cells after optic chiasmal decompression

Investigated the time course of visual field recovery and changes of retinal ganglion cells after chiasmal decompression.

Prospective analysis – 19 patients, pre op, then 1, 3 and 6 months after surgery

Used standard automated perimetry, optical coherence tomography, photopic negative response (PhNR).

Compared to 20 controls with normal eyes Pre operatively, all parameters worse in

affected eyes as compared to control

The time course of visual field recovery and changes of retinal

ganglion cells after optic chiasmal decompression

After surgery, visual field significantly improved by 3 month.

Retinal nerve fiber layer (RNFL) thickness and ganglion cell complex (GCC) area were significantly reduced at three months

At six months post op: average RNFL thickness, GCC area and PhNR/b-wave ratio showed significant improvement

Visual fields were significantly correlated with RNFL thickness and GCC area.

VF recovery preceded demonstrable retinal regeneration

The time course of visual field recovery and changes of retinal

ganglion cells after optic chiasmal decompression

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

Clinic and Spine Institute. Feb 2013. pgs 1-6 Danesh-Meyer HV, Papchenko T. In vivo retinal nerve fibery layer

thickness measured by optical coherence tomography predicts visual recovery after surgery for parachiasmal tumors.

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.

Galal A, Faisal A. Determinants of postoperative visual recovery in suprasellar meningiomas.

Loeffler JS, Shih HA. Radiation therapy in the management of pituitary adenomas.

Moon CH, Hwang SC, Ohn YH, Park TK. The Time course of visual field recovery and changes of retinal ganglion cells after optic chiasmal decompression. Invest Ophthalmol Vis Sci. 2011 Oct 10;52(11):7966-73.

Thank you for listening!