A 32-Year-Old Woman With Decreased Vision in Her Left Eye

Robert Garoon, MD; Rod Foroozan, MD

Disclosures

July 01, 2014

Clinical Presentation

A 32-year-old woman with a known brain tumor was referred for an evaluation of longstanding poor vision in her left eye. She initially presented with amenorrhea and was found to have elevated prolactin levels and a pituitary adenoma measuring 1.5 cm in diameter. She was started on cabergoline, and the adenoma subsequently decreased in size to 1.0 cm x 0.7 cm x 0.7 cm. While on treatment, she became pregnant and was referred to the ophthalmology service at week 9 of her pregnancy.

Her medical history included pituitary prolactin-secreting macroadenoma. Her medications included cabergoline, prenatal vitamins, and a multivitamin. Testing for other endocrine disorders was negative. She denied any history of trauma to the eyes or face. She denied any family history of blindness or glaucoma. She had not had any prior eye surgery. She denied smoking, alcohol use, or other drug use.

On ocular examination, visual acuity with correction was 20/20 in the right eye and counting fingers at 1 inch in the left eye. Both pupils were symmetric and brisk with no relative afferent pupillary defect. Visual fields by confrontation were full on the right and suggested a central scotoma on the left. Extraocular movements were full, and ocular alignment by the Krimsky test showed a 15-prism diopter exophoria. Amsler grid testing was normal in the right eye, but the patient was unable to see the grid with the left eye due to poor central vision. Color vision testing with Ishihara pseudoisochromatic plates revealed 10/10 in the right eye and 0/10 in the left eye. Intraocular pressures were 10 mm Hg in each eye by applanation. Slit lamp examination of the anterior segment was within normal limits including a clear cornea, deep and quiet anterior chamber, round and reactive iris, and a clear lens in each eye. No cells were seen in the vitreous.

Additional Workup

The patient's most recent MRI of the brain with contrast showed no compression of the optic nerves or chiasm. There were not any congenital structural abnormalities on MRI.

Fundus photography revealed a hypoplastic left optic disc and a peripapillary staphyloma related to high myopia. The right optic disc was larger and had a cup-to-disc ratio of 0.2. The left optic disc had no central cup (Figure).

Automated perimetry showed a few points of reduced sensitivity in both eyes.

Retinoscopy showed -25 D of myopia in the left eye.

Figure. Fundus photographs show a healthy optic disc in the right eye and a hypoplastic disc in the left eye.

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