Sudden visual loss and headache: important symptoms of pituitary disease

Abstract

A63-year-old man presented to the ophthalmology department with a 24-hour history of loss of vision in the right eye and 3 days of severe frontal headache. Six weeks earlier a supero-temporal field defect was observed in the left eye during examination by his optician. A routine referral to the ophthalmology department for assessment of possible glaucoma was made. On examination he was alert and orientated. The visual acuity was hand movements in the right eye and 6/12 in the left eye with a dense right relative afferent pupillary defect. Visual fields tested by confrontation demonstrated a bitemporal loss. This was confirmed by formal Goldmann visual fields (Figure 1). There was no papilloedema or external ophthalmoplegia and further ophthalmic examination was unremarkable. There were no focal neurological signs and his blood pressure was normal. Serum prolactin was 400U/litre (normal range: 100–500 mU/litre). A computerized tomography scan (Figure 2) revealed an intrasellar mass expanding the sella turcica and extending into the suprasellar cistern. There were small high density foci suggesting a recent haemorrhage within a pituitary adenoma. The patient underwent transphenoidal decompression of the pituitary tumour and histopathology confirmed haemorrhagic pituitary adenoma. Repeat visual fields within 1 week of surgery (Figure 3) illustrate dramatic recovery of visual function. Two weeks postoperatively, the patient's visual acuity had improved to 6/24 in the right eye and 6/9 in the left with continued improvement in the visual field. After 5 months his visual acuity was 6/18 right and 6/6 left with almost complete recovery of his visual fields and he was able to return to driving.