Tears for Dinner

A 66-year-old Puerto Rican man had progressively worsening epiphora with mastication x 1 year. The epiphora was associated with jaw winking and could be brought on while masticating food or blowing air. On examination, vision was 20/20 and 20/20 OS, with normal color vision, full extraocular movements and ortho gaze on cover/uncover testing. Worth 4 dot testing was normal. There was no rAPD and no anisocoria. Slit lamp and dilated fundus exam were normal. Humphrey visual field testing revealed generalized depression worse temporally OD > OS. OCT RNFL testing was normal. MRI brain with and without contrast a pituitary microadenoma measuring 8mm x 8 mm x 7.6 mm. The right side of the pituitary gland had a bulging convex superiorly with hypoenhancing soft tissue signal intensity which infiltrated into the right cavernous sinus with encasement of the right carotid artery.