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Opthalmologic Evaluation of Pituitary Adenomas

What should be included in a “baseline” eye examination? 

  • Visual acuity (“center vision”) 
  • Visual field (“peripheral or side vision”) 
  • Pupil exam (“the black part of the eye”) 
  • Slit Lamp exam (exam of the structures of the “front part of the eye”) 
  • Motility exam (“how the eye moves”) 
  • Dilated fundus exam (“looking at the back of the eye including the optic nerve”) 


What symptoms will the patient have? 

  • Unexplained usually painless decreased visual acuity or visual field-common 
  • Double vision (diplopia)-less common 
  • Droopy eyelid (ptosis)-less common 


Why should every patient with a pituitary adenoma have an eye exam?

  • Visual loss may be the presenting and only sign of pituitary tumor
  • Visual improvement may indicate treatment response of pituitary tumor
  • Progressive visual loss may indicate recurrence of tumor
  • Baseline ophthalmologic exam


What is the eye doctor looking for?

  • Decreased visual acuity or visual field
  • Abnormalities in the response of the pupil
  • Abnormal eye movements
  • Optic atrophy (visible damage to the optic nerve)


How does a pituitary adenoma decrease vision?

  • Pituitary tumors (and other types of brain tumors) can cause visual loss by pressure (compression) of the visual pathway
  • Depending on where the tumor is located the vision loss may be in one or both eyes and may affect central vision or side vision


How does a pituitary tumor cause double vision?

  • Compression of the nerves that control eye movement (ocular motor nerves or cranial nerves III, IV, and VI)
  • Loss of vision can cause loss of the ability to keep the eyes aligned (fusion)


How does pressure on the anterior visual pathway cause visual loss?

  • Pressure on the optic nerve causes loss of vision in the ipsilateral (“same side”) eye
  • Pressure on the optic chiasm causes a bitemporal hemianopsia (“loss of temporal side vision in each eye”)
  • Pressure on the optic tract causes a homonymous hemianopsia (Homo: same, Hemi: half, Opsia: loss of vision)


What factors make it more or less likely that the patient with visual loss due to a pituitary tumor will recover vision?

  • Age (younger patients do better)
  • Vasculopathic risk factors: patients without hypertension, diabetes or other medical problems do better
  • Duration of visual loss (the longer the symptoms have been present, the less likely the vision will return
  • Presence of optic atrophy (optic atrophy implies some component of irreversible visual loss)


What is the anatomy of the visual pathway?

  • Visual information passes through the cornea (the clear part of the eye), the lens, to the retina (like film in a camera) and to the optic nerve, optic chiasm (a crossing point), then to the optic radiations and the occipital cortex
  • Pituitary adenomas affect the anterior (or front part of the brain) visual pathway


Is the visual loss reversible after treatment?

  • If the pressure on the visual pathway can be relieved most patients experience improvement in vision after treatment


How often should I see the eye doctor?

  • Preoperative baseline
  • Postoperative baseline
  • Postoperative 3 months
  • Postoperative 9-12 months
  • Yearly if stable


When should I call my eye doctor?

  • Blurry central or side vision
  • Double vision
  • Droopy eyelid


One additional note

  • Persons with Cushing’s should also be checked for cataracts since long term exposure to cortisol increases your chances of cataracts.


Author: Dr. Andrew Lee, MD (Spring, ’98)

Editor’s Note: Dr. Andrew G. Lee, MD, Baylor College of Medicine, Division of Neurosurgery, MD Anderson Cancer Center, University of Texas, Neuro-ophthalmology Unit, Department of Ophthalmology, Neurology and Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, MD Anderson Cancer Center, University of Texas

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