Article

CLINICAL: INTERDISCIPLINARY

KEEP AN EYE ON THE PITUITARY

UTILIZE TEAM CARE IN THE DIAGNOSIS AND MANAGEMENT OF PITUITARY ADENOMA

A 54-YEAR-OLD, black male presented with complaints of an 18-month “curtain-like” peripheral vision loss affecting both eyes. The symptoms began as a small VF defect affecting the left side OS. Recently, he noted a rapidly progressing VF defect affecting the right side OD. Upon questioning, the patient said that for the past eight months he experienced headaches, which seemed to have diminished to some degree once he “cut out caffeine.” Past medical history was unremarkable, but he recently moved to Florida and had not received any medical care in the state. He denied any sexual dysfunction, breast enlargement or breast discharge. Past ocular history revealed possible epiretinal membranes OU.

BCVA was 20/50 OD and 20/30 OS. Extraocular muscles were full, smooth and without restriction. Pupils were equal, round, reactive and had no afferent pupillary defect. IOP was 12mm Hg OD and OS. Anterior slit lamp exam was unremarkable. Dilated fundus exam revealed bitemporal optic nerve pallor with a c/d ratio of .5/.5 OU. Maculae were flat and evenly pigmented. Peripheral retinal exam did not reveal any evidence of pathology.

SD-OCT with macular cube analysis showed vitreomacular adhesions OU. In addition, nerve fiber layer analysis showed mild inferiotemporal nerve fiber layer defects (NFLD) OU with a concurrent superiotemporal NFLD OS; corroborating ganglion cell complex (GCC) defects also were noted OU. A Humphrey VF Central 24-2 SITA standard revealed correlating incongruent bitemporal VF defects affecting OD>OS.

Optic nerve pallor present OD
Courtesy of Dr. Diana Shechtman

Given that a tumor on the pituitary gland, or pituitary adenoma, may result in patient complaints of ocular neurological dysfunctions, including bitemporal VF defects, decreased VA, diplopia and/or headaches, the eye care physician may play a critical role in the initial diagnosis of pituitary adenoma, as well as in the continuous management of these patients.

DIAGNOSIS

The patient was diagnosed with a suspected pituitary adenoma. Given the aggressive nature of the symptomatology and that the patient did not have an established physician in the state, we consulted with an emergency room (ER) attending physician and explained the patient’s status.

The patient was then referred to the ER for proper imaging and blood testing. A summary report regarding the ocular findings and necessary testing was given to the patient.

Optic nerve pallor present OS
Courtesy of Dr. Diana Shechtman

EMERGENCY

Due in part to the communication with the ER physician prior to the patient presenting with his referral, a MRI was performed. The MRI revealed a 2.7cm x 3.2cm x 3cm pituitary mass, compressing on both optic nerves with displacement of the dorsal and cisternal segment. Initial hormone blood testing revealed prolactin, 17.1 (normal values are 2 to 19); insulin-like growth factor, 99 (normal values: 90 to 360), growth hormone, 0.05 (normally <5), adrenocorticotropic hormone, 12 (normally 5 to 27); cortisol 7.7 (normal values are 3 to 10).

Because of the imaging and serology results, both neurology and endocrinology consults were warranted.

NEUROLOGY

In most cases of neurologic emergencies, an ER will be the primary location for initial referral to stabilize the patient’s condition. (Rarely, when a patient may have an established relationship with a neurologist and recognized neurologic diagnosis, the neurologist or neuro-ophthalmologist may be the first point of contact prior to an ER referral.) In all cases that present to the ER, when a neurologic condition has been diagnosed and the patient has been stabilized, a neurologist, neuro-ophthalmologist and/or neurosurgeon will be consulted and management options presented based on the specific diagnosis.

For this case, the patient required a broader coordination of care. The diagnosis of a pituitary macroadenoma (>10mm) was confirmed and an appointment was set for a neurosurgeon consultation to evaluate whether resection via trans-sphenoidal hypophysectomy could be beneficial.

ENDOCRINOLOGY

Typical disease experts in the field of endocrinology diagnose and manage diabetes and thyroid regulatory disorders. As optometrists, our relationships with endocrinologists are important, as so many endocrine disorders have significant ocular findings and associated visual risks.

In this patient, the tumor was not a prolactin-secreting pituitary adenoma (prolactinoma). Therefore, further blood tests were ordered, including initial hormonal tests for thyroid function, testosterone and luteinizing and follicle-stimulating hormone, to determine whether the patient may benefit from hormonal therapy to shrink the tumor prior to surgery. The patient management required both the endocrinologist and neurologist/neurosurgeon to coordinate management in order to further stabilize the patient.

OPTOMETRY - CONTINUED CARE

In continuing care, the optometrist’s role is to serve as a mediator and advocate for the patient with different medical specialists. Optometrists should continue to serve in a primary eye care function by monitoring the patient’s visual status.

While certain treatments may be required for the patient’s overall wellbeing — such as surgical removal of a mass — vision may still be at risk during and after management. In some cases, with specific secondary ocular complications, such as optic nerve compression following intracranial bleeding post-operatively, further coordination of care with ophthalmology may be warranted; specifically, if complications require ocular management beyond your scope of practice.

Finally, in cases in which vision is non-recoverable, having patients work with low vision specialists on orientation and mobility training may be warranted to expand the patient’s VF and maintain the highest possible quality of life.

This patient was scheduled for a comprehensive follow-up eye exam, including optic nerve head photos, repeat VF and SD-OCT, as well as NFLD and GCC testing to monitor visual function following treatment. Continuous long-term care also is crucial to determine any progression and/or reoccurrence of the adenoma. OM