Vaidya Keepa, Tamang Sandip
Department of Ophthalmology, Eastern Regional Referral Hospital, Mongar, Bhutan.
Nepal J Ophthalmol. 2024 Jan;16(31):80-86. doi: 10.3126/nepjoph.v16i1.60134.
Asymmetric visual field defects with a high cup-to-disc ratio resembling glaucomatous damage can be the only clinical features of a pituitary macroadenoma with apoplexy, posing diagnostic challenges.
A 39-year-old man presented with a history of gradual onset, progressive visual obscuration in the right visual field for one month without any other accompanying neurological symptoms. On examination, his intraocular pressure (IOP) was 16 mmHg in both eyes. Posterior segment examination revealed a cup to-disc ratio (CDR) of 0.8 in the right and 0.7 in the left eye, with concentric neuroretinal rim thinning and mild temporal disc pallor. These findings led to the diagnosis and treatment of normal tension glaucoma (NTG) elsewhere. Visual field examination showed field defects featuring a junctional scotoma. The MRI scan of the brain revealed a well-defined mass lesion situated in the sella suggestive of pituitary macroadenoma with possible apoplexy confirmed later through histopathological examination. The neurosurgery team successfully removed the tumor through the endoscopic endonasal trans-sphenoidal approach and the patient reported significant improvement in vision and visual field defects.
In our case, visual signs and symptoms were the only presenting features, caused by pituitary macroadenoma with apoplexy, which can be a potentially life-threatening condition. Although pituitary apoplexy is an acute condition with numerous neurological signs and symptoms, visual symptoms with high CDR and neuroretinal rim thinning with mild temporal disc pallor were the only features seen in our case, posing a diagnostic challenge. There were no associated systemic manifestations. However, the patient had a favorable outcome because of prompt diagnosis and multidisciplinary management.
The spectrum of clinical manifestations of pituitary macroadenoma with apoplexy should encompass a gradual onset, progressive asymmetric visual field defect with temporal disc pallor to facilitate timely diagnosis and effective management.
具有类似于青光眼性损害的高杯盘比的不对称视野缺损可能是垂体大腺瘤伴卒中的唯一临床特征，这给诊断带来了挑战。
一名39岁男性，有逐渐起病的病史，右侧视野渐进性视力模糊1个月，无任何其他伴随的神经症状。检查时，他双眼眼压（IOP）均为16 mmHg。眼部后段检查显示右眼杯盘比（CDR）为0.8，左眼为0.7，伴有同心性神经视网膜边缘变薄和轻度颞侧视盘苍白。这些发现导致在其他地方诊断和治疗正常眼压性青光眼（NTG）。视野检查显示视野缺损具有交界性暗点特征。脑部MRI扫描显示蝶鞍区有一个边界清晰的肿块，提示垂体大腺瘤伴可能的卒中，后来通过组织病理学检查得以证实。神经外科团队通过内镜鼻内经蝶窦入路成功切除了肿瘤，患者报告视力和视野缺损有明显改善。
在我们的病例中，视觉体征和症状是唯一的表现特征，由垂体大腺瘤伴卒中引起，这可能是一种潜在的危及生命的疾病。尽管垂体卒中是一种有众多神经体征和症状的急性疾病，但在我们的病例中，高CDR的视觉症状、神经视网膜边缘变薄和轻度颞侧视盘苍白是仅有的特征，这给诊断带来了挑战。没有相关的全身表现。然而，由于及时诊断和多学科管理，患者预后良好。
垂体大腺瘤伴卒中的临床表现谱应包括逐渐起病、进行性不对称视野缺损伴颞侧视盘苍白，以便于及时诊断和有效管理。
