Junctional Scotoma from a Sellar Mass

This is a case of a 55-year-old woman presenting with gradual painless vision loss in both eyes. Although visual acuity was 20/20 in both eyes, there was a left relative afferent pupillary defect and diffuse pallor of both optic nerves (Figure 1). Visual fields (24-2 SITA-Fast) showed a temporal defect in the right eye and more diffuse loss in the left eye respecting the vertical meridian superiorly (Figure 2). The visual field defect localizes to the distal portion of the optic nerve at the angle of the chiasm and is called a junctional scotoma (Figure 3). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) showed thinning superiorly in the right eye and more diffusely in the left eye (Figure 4 and 5). OCT of the ganglion cell layer (GCL) showed nasal loss in the right eye corresponding to the temporal visual field defect and more diffuse loss of macular ganglion cells in the left eye with relative sparing of the infero-temporal macula corresponding to the diffuse visual field loss with relative sparing of the supero-nasal visual field (Figure 6). MRI showed compression of the left pre-chiasmatic optic nerve and chiasm by a pituitary adenoma (Figure 7). The most common cause of a junctional scotoma, as shown in this case, is a mass such as a neoplasm or aneurysm. [[ Number of Figures and legend for each: 7 figures included. Figure 1. Optic disc photos at presentation showed diffuse pallor in both eyes. Figure 2. Visual fields (24-2 SITA-Fast) showed a temporal defect in the right eye and more diffuse loss in the left eye respecting the vertical meridian superiorly. Figure 3. The visual field defect localized to the distal portion of the optic nerve at the angle of the chiasm and is called a junctional scotoma. Figure 4. Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) showed thinning superiorly in the right eye and more diffusely in the left eye. Figure 5. Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) showed thinning superiorly in the right eye and more diffusely in the left eye. Figure 6. OCT of the ganglion cell layer (GCL) showed nasal loss in the right eye corresponding to the temporal visual field defect and more diffuse loss of macular ganglion cells in the left eye with relative sparing of the infero-temporal macula corresponding to the diffuse visual field loss with relative sparing of the supero-nasal visual field. Figure 7. Coronal T2 MRI sequences are shown demonstrating compression of the left pre-chiasmatic optic nerve and chiasm by a pituitary adenoma.]]