Download Aruoriwo M Oboh-Weilke, MD * Florian Weilke, MD # * Georgetown

Discovery of a large Pituitary macroadenoma
on evaluation of a patient with Pars Planitis
ARUORIWO M OBOH-WEILKE, MD*
FLORIAN WEILKE, MD#
* GEORGETOWN UNIVERSITY HOSPITAL
# SANFORD HEALTH
The authors have no financial interest in the subject matter of this poster
Purpose
 We report a case of a patient who was referred
for evaluation and treatment of an 11year history
of pars planitis.
 The patient recently had a history of headaches
 Ophthalmologic exam revealed elevated discs
and vitreous cells.
 An investigation revealed a large enhancing
sellar mass compatible with a pituitary
macroadenoma.
INTRODUCTION
 Pars planitis is an idiopathic clinical entity with
bilateral intermediate uveitis1
 In addition to aggregates in the inferior pars
plana (snowbanking), vitritis and CME, optic
nerve head swelling can be one of the ocular
manifestations 1
 The ocular symptoms are compatible with those
seen in uveitis such as red eye, pain and
photophobia 1. However, intractible posterior
headaches is an unusual presentation for a
patient with pars planitis.
INTRODUCTION
 Pituitary tumors can be grouped into nonsecreting and secreting types 2.
 Tumors of the non-secreting types more often
present with loss of vision while the secreting
type more often present with endocrine
dysfunction 2.
 The presence of headache in pituitary tumor is
due to a combination of factors, including
intrasellar pressure , tumor extension,
relationship with the sellar structures, patient
predisposition, and functional disturbance within
the hypothalamo-pituitary axis 3.
CASE REPORT
 A 28 year old African American male was referred for
evaluation.
 He had a history of Pars planitis from ages 11 to 22. Due
to inadequate insurance coverage, he had not followed
up with his ophthalmologist for 6 yrs.
 For the past year, the patient had developed posterior
headaches and decreased vision in the right eye which
prompted him to seek out medical care.
 On presentation to his Ophthalmologist’s office he was
noted to have elevated optic discs, vitreous cells and a
decreased best corrected visual acuity. He was then
referred for further evaluation and treatment
CASE REPORT
 On physical examination, the patient’s VA was:
20/50 OD, 20/25 OS
 EOM, pupils and IOPs were all within normal.
 Color plates were diminished on the left.
 Slit Lamp Exam revealed fine keratic precipitates
OD. 1+ cell/flare OD, Trace cells/flare OS.
 Dilated fundus exam revealed vitreous cells,
significant disc elevation OU and cystoid macular
edema OD
 Snowbanking of the retina was also present on
examination OD
RESULTS
The Patient was started on Durezol OU and
Nevanac OD.
A systemic work-up was undertaken which
included a CBC, RPR, FTA-ABS, ACE levels,
lyme titers and an MRI of the brain/orbits
with and without contrast.
A referral to the retina service was also put in
place
RESULTS
 The blood work revealed negative results,
 MRI of the brain revealed an enhancing sellar
mass measuring 31x34x24mm. The optic
chiasm was compressed and displaced
upwardly. The mass also extended laterally to
the carotid arteries and cavernous sinus.
Based on imaging characteristics it was
believed to be a pituitary macroadenoma.
RESULTS
 The patient was sent to a neuroophthalmologist
for evaluation. On visual field testing, he was
noted to have a significant bitemporal field
defect which he was previously unaware of .
 He underwent a transphenoidal excision of the
mass
 Subsequently, he recovered most of his visual
field defect. The patient's vision also significanty
improved after the treatment of his cystoid
macula edema
RESULTS
T1 weighted post-contrast image through the sella.
RESULTS
Visual Field Pre-op
Visual Field Post-op
DISCUSSION
 Pars planitis is an idiopathic clinical entity
with bilateral intermediate uveitis. It is
typically seen in young adults and children 1.
 It can have many variable presentations
including, vitreous hemorrhage due to
peripheral neovascularization 4, 1.
 Neovascularization of the disc has also been
reported in patients with pars planitis 5.
 The disease can be chronic or self-limited 1.
DISCUSSION
Recurrences respond well to steroids. The
Prognosis is usually good if the patient’s
disease is not complicated by CME or
posterior subcapsular cataracts . Pars plana
vitrectomy may be an option for
complications such as retinal detachments 1.
A common complaint at presentation could be
decreased vision due to uveitis or CME.
However, headaches are not typically a
presenting symptom of pars planitis
DISCUSSION
 In about 75% of the cases, pituitary adenomas have
hormonal abnormalities . In contrast, the nonhormonally active lesions become symptomatic due
to their size. Resulting in headache, visual
abnormalities such as a bitemporal hemianopsia .
Cranial nerve palsies, CSF rhinorrhea have also been
reported as presenting symptoms 6.
 These lesions even with extention into the
suprasellar space can be removed transsphenoidal
ly. Giant adenomas are best controlled with
craniotomy and/or a combined, transphenoidal and
transcranial route 7.
CONCLUSION
This case highlights the importance of a systemic
work-up in patients who present with new
symptoms, despite already having a diagnosis
that explains some of the signs on exam. More
than one pathology may be present in a patient
with an already existing condition.
REFERENCES
1 Retina and Vitreous. Basic and Clinical Science Course 2007-2008; 182
2 Neuro-Ophthalmology. Basic and Clinical Science Course 1999-2000;
94-95
3 Headache associated with pituitary tumors. J Headache Pain. 2009
Feb; 10(1):15-20
4 Pars Planitis presenting with vitreous hemorrhage. Ophthalmic Surg.
1993 Sep;24(9):630-1
5. Neovascularization of the disc in Pars Planitis. Retina. 1990; 10(4):
269-73
6 Grossman RI, Yousem DM. Neuroradiology. 2nd ed. Philadelphia:
Mosby; 2003; 532-543
7 Combined endoscopic transsphenoidal-transventricular approach for
resection of a giant pituitary macroadenoma. World Neurosurgery.
2010;74(1):161-4
Thanks
 Special thanks to:
 David Wagner, MD
 Benjamin Osborne, MD
 Josef Tamory, COMT
 Jay Lustbader, MD