A 45-Year-Old Man With Progressive Vision Loss in One Eye

Carlo R. Bernardino, MD


February 19, 2014

Differential Diagnosis

On the basis of the patient's findings, the likely diagnosis is a midline intracranial tumor.

The diagnosis of glaucoma is unlikely. Although the patient has optic nerve head asymmetry, intraocular pressures were not significantly elevated, and the dense temporal visual field defect does not correlate with the mild optic nerve cupping in the left eye.

Nonarteritic ischemic optic neuropathy is associated with an optic nerve that lacks a cup, often referred to as "disc at risk." The visual field defect of nonarteritic ischemic optic neuropathy is altitudinal and does not spare the macula.

Classic findings in occipital stroke include a normal ocular anatomical examination in the setting of profound loss of vision or homonymous hemianopsia. However, central vision sparing is often present, and a bitemporal presentation would be unlikely.

A midline intracranial tumor, such as a pituitary macroadenoma, a meningioma, or a sphenoid sinus tumor, presents with bitemporal visual field defects because the tumor can cause compression or invasion of both optic nerves.

Systemic Evaluation and Clinical Course

Neuroimaging is recommended for any case that is suspicious for an intracranial tumor.

MRI of the brain and brainstem revealed an expanded sella turcica with a mass expanding superiorly and displacing the chiasm, consistent with a pituitary macroadenoma. The mass measured 3.5 x 2.5 cm (Figure 3).

Figure 3. MRI of the brain, axial cut T2, demonstrates a large pituitary tumor consistent with macroadenoma.


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