indescribable vision loss
DESCRIPTION
pituitary tumorTRANSCRIPT
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Indescribable Vision Loss Noushin S. Ahmed, O.D. Ocular Disease Resident Seidenberg Protzko Eye Associates
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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
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Ocular History � Traumatic penetrating injury OD 1975
� Cataract surgery OD with BCVA 20/40 2012 � Iris reconstruction 2012
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Medical History � Hypertension
� Treated with Lisinopril 20mg qd po
� Hypercholesterolemia � Treated with Lipitor 20mg qd po
� Hayfever
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Family History � Unremarkable
� Former smoker x 10 years
� denies alcohol & recreational drug use
Social History
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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
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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
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Additional Tests � Ishihara
OD 5/7 OS 5/7
� Red Cap Test OS desaturated
� Subjective Brightness OS decreased
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HVF 24-2
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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
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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
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1. Homonymous Hemianopsia, Bilateral
2. Crystal Deposit, OS
3. Cataract, Incipient OS
4. Pupillary abnormalities, OD
5. After cataract obsucration, OD
Assessment Plan
1. Urgent Evaluation w/neurosurgery and neuroimaging
2. Not clinically significant
3. Incipient—not cause of visual loss
4. H/o successful iris sutures
5. Progressing PC haze
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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
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Pituitary Adenoma
� Funtional � Non-functional
� Pre-fixed � Post-fixed
� Hardy Wilson Classification system1 � Stage 0 � Stage A � Stage B � Stage C
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Systemic Symptoms
� Headache � Amenorrhea � Galactorrhea � Impotence � Fatigue
http://2.bp.blogspot.com/-RC9sou7utqE/UYuh1YfpZDI/AAAAAAAAAMQ/l7rZRIPuMbk/s1600/Migraine%2BII.jpg
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Visual Complaints � Decreased vision � Loss of depth perception � Difficulties with near tasks � Diplopia � Photophobia � Dyschromatopsia
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Visual Loss Determinants
� Tumor size � Growth direction � Rate of Growth � Individual anatomy
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Visual Symptoms � Chiasm
� VF defect � Intermittent diplopia � Seesaw nystagmus
� 3rd Ventricle � Hydrocephalus
� Upgaze � Light-near diss
� Convergence-retraction Nystagmus
� Papilledema
� Cavernous sinus � CN III
� Upgaze � Downgaze � Medial gaze � Diplopia � Ptosis � Mydriasis
� CN IV & VI � LR & SO palsies
� CN V1 � Loss of sensation
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Visual Pathway
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http://www.medicinemcq.com/index.php/journals/sub_details/138/39/FMGE-MARCH-2012-ENT-AND-OPHTHALMOLOGY
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VF Defect & Pituitary Adenoma
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VF Defect & Pituitary Adenoma
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VF Defect & Pituitary Adenoma
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Fundus Findings Temporal Pallor Band/Bowtie Atrophy Optic Atrophy Papilledema
http://ophthalmology.stanford.edu/blog/archives/2009/10/bowtie-optic-at.html
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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
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Treatment � Goals
� Control growth � Normalize function � Preserve/restore
vision
� Surgery � Medical Therapy � Radiotherapy � Expectant
Observation
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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
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Risks of Treatment � Surgical Removal
� Direct injury/devascularization of optic apparatus
� Prolapse into empty sella
� Orbital Fracture � Hematoma � Cerebral
vasospasm
� Bromocriptine � Visual
hallucinations � Tumor re-
expansion � Chiasmal
herniation
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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
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Risk Factors � Macroadenoma � Previous Visual
Impairment � Bottleneck/dumb-
bell shaped tumor � Previous surgery � Lumbar
subarachnoid catheter
http://www.neurologyindia.com/viewimage.asp?img=ni_2013_61_2_122_111114_f5.jpg
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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
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VF Improvement 1. Early Fast Phase: days – 1 week 2. Slow Recovery Phase: weeks – 2 months 3. Late Phase: months – years
**improvement: as long as 5 years post-op
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Post-op management � Multidisciplinary
approach
� Baseline Exam � VA � Color � Motility � VF
� Post-op � 2-3 months � 6-12 months
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Conclusion � Multidisciplinary � Patients’ varying symptoms and status � Understanding VF, afferent visual
pathway, anatomy and CN exam
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References 1. Bynke, Olof. "Incidence of Neuro-ophthalmic Manifestations of Pituitary Adenomas in
the Referral Area of Linkoping, Sweden, 1965–1984." Neuro-Ophthalmology 7.3 (1987): 165-73. Print.
2. Chhabra, Vaninder S., MD, and Nancy J. Newman, MD. "The Neuro-Ophthalmology of Pituitary Tumors." Comprehensive Ophthalmology Update 7.5 (2006): 225-37. Print.
3. Chiu, Eric K., and Jeffrey W. Nichols. "Sellar Lesions and Visual Loss: Key Concepts in Neuro-ophthalmology." Expert Review Anticancer Therapy 6.9 (2006): S23-28. Print.
4. Chung, Sophia M., MD. "Neuro-ophthalmic Manifestations of Pituitary Tumors." Neuro-Ophthalmology for Neurosurgeons 10.4 (1999): 717-29. Print.
5. Dekkers, O. M., S. Hammer, R. J W De Keizer, F. Roelfsema, P. J. Schutte, J. W A Smit, J. A. Romijn, and A. M. Pereira. "The Natural Course of Non-functioning Pituitary Macroadenomas." European Journal of Endocrinology 156.2 (2007): 217-24. Print.
6. Dhar, Meenakshi Y., MS, and Niranjan K. Pehere, MS. "Unusual Visual Manifestations of Pituitary Tumours." Kerala Journal of Ophthalmology XIX.2 (2007): 147-55. Print.
7. Elgamal, Ehud, E. Oosman, S. El-Watidy, A. Hazem, N. Al-Khawajah, N. Jastaniyah, and M. Al-Rayess. "Pituitary Adenomas: Patterns of Visual Presentation and Outcome After Transsphenoidal Surgery - An Institutional Experience." The Internet Journal of Ophthalmology and Visual Science 4.2 (2006): n. pag. Print.
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References cont. 8. Fu, Xiangping, and Hongqi Wang. "Ocular Symptoms of Tumors at Sella Turcica Region."
Eye Science 12.3 (1996): 166-68. Print. 9. 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 28.9 (2007): 1380-384. Print.
10. Kedar, Sachin, Deepta Ghate, and Jamesj Corbett. "Visual Fields in Neuro-ophthalmology." Indian Journal of Ophthalmology 59.2 (2011): 103. Print.
11. Lee, Jung Pil, In Won Park, and Yun Suk Chung. "The Volume of Tumor Mass and Visual Field Defect in Patients with Pituitary Macroadenoma." Korean Journal of Ophthalmology 25.1 (2011): 37. Print.
12. Monteiro, Mário L.r., Beatriz K. Zambon, and Leonardo P. Cunha. "Predictive Factors for the Development of Visual Loss in Patients with Pituary Macroadenomas and for Visual Recovery after Optic Pathway Decompression." Canadian Journal of Ophthalmology 45.4 (2010): 404-08. Print.
13. Schmalisch, Kathrin, Monika Milian, Thilo Schimitzek, Wolf A. Lagrèze, and Juergen Honegger. "Predictors for Visual Dysfunction in Nonfunctioning Pituitary Adenomas - Implications for Neurosurgical Management." Clinical Endocrinology 77.5 (2012): 728-34. Print.
14. Simon, Sumu, David Torpy, Brian Brophy, Peter Blumbergs, and Dinesh Selva. "Neuro-ophthalmic Manifestations and Outcomes of Pituitary Apoplexy--a Life and Sight-threatening Emergency." The New Zealand Medical Journal 124.1335 (2011): 52-58. Print.