Complete Surgical Resolution of Bilateral Total Opthalmoplegia without Visual Field Defect in an Acromegalic Patient Presented with Pituitary Apoplexy

Abstract

Abstract. Pituitary apoplexy (PA), which is one of the most serious life-threatening complications of pituitary adenoma, is characterized by abrupt onset of headache, nausea, vomiting, visual disturbances and oculomotor paresis. Combination of oculomotor cranial nerve paralysis with normal visual fields is very rare in PA. We report a 60-year-old acromegalic man presented with panhypopituitarism and bilateral total opthalmoplegia without a visual field defect. At initial evaluation his clinical findings were compatible with adrenal crisis and eye examination revealed total opthalmoplegia, bilateral ptosis and normal vision. MRI showed a large heterogeneous mass in the pituitary fossa. Although clinical findings due to adrenal crisis improved after glucocorticoid therapy there was no improvement in opthalmoplegia and ptosis. The patient underwent transsphenoidal excision of the pituitary mass. Histological examination revealed an adenoma with large areas of hemorrhagic infarction and most of the cells were positive for GH in immunohistochemical analysis. Although opthalmoplegia was severe at presentation, total recovery was achieved 3 months after transsphenoidal surgery. Therefore the presented case clearly demonstrates that opthalmoplegia without a visual field defect due to PA has a good prognosis and early diagnosis and treatment including surgical decompression are crucially important.

Pituitary Apoplexy Presenting Atypical Time Course of Ophthalmic Symptoms

“…Several reports have shown oculomotor nerve palsy as a clinical presentation of pituitary apoplexy and it usually has an abrupt onset (Chen et al 1999;Lau et al 2007;Tanriverdi et al 2007). Gradually worsening of this symptom is atypical for pituitary apoplexy and is more suggestive of a cerebral aneurysm.…”

“…It has been reported that the patients with oculomotor nerve palsy due to pituitary apoplexy has a good postsurgical recovery (Chen et al 1999;Lau et al 2007;Tanriverdi et al 2007). Early diagnosis and treatment including surgical decompression are crucially important in patients with oculomotor nerve palsy in pituitary apoplexy; however, it should be noted that its symptoms could slowly progress and the imaging could mimick cerebral aneurysm or cystic lesion.…”

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

“…Isolated acute cranial nerve (CN) palsies have been reported (82,83,84,85) and they usually indicate a milder episode having good prognosis …”

“…The third CN is most frequently affected due to its position, more close to the sella and possibly to its compression onto the interclinoid ligament, but multiple CN palsies and even bilateral lesions have been reported (82,85). Impaired consciousness is a sign of severity and it occurs more frequently in patients with associated predisposing factors (33).…”

Chorio-retinal thickness measurements in patients with acromegaly

“…Increased corneal thickness, pigmentary degeneration of the retina, melanocytic tumours of the choroid, enlarged extraocular muscles, proptosis, and total ophthalmoplegia are some of the ocular manifestations of acromegaly. [6][7][8][9][10][11] On the other hand, there is a gap in the literature about the impact of acromegaly on the fovea, optic nerve head, and choroid.…”