Retinal Hemifield Slide Phenomenon as a Presenting Symptom of Pituitary Abscess 2 Months After Pituitary Adenoma Resection

Clinical Correspondence Section Editors: Robert Avery, DO Karl C. Golnik, MD Caroline Froment, MD, PhD An-Guor Wang, MD Retinal Hemifield Slide Phenomenon as a Presenting Symptom of Pituitary Abscess 2 Months After Pituitary Adenoma Resection Lindsey Schwartz, MD, Subahari Raviskanthan, MBBS, Peter W. Mortensen, MD, David S. Baskin, MD, Andrew G. Lee, MD T he retinal hemifield slide phenomenon (RHSP) is a nonparetic, typically intermittent binocular diplopia occurring from the inability to fuse juxtaposed intact nasal visual hemifields because of the lack of visual field overlap between the 2 eyes. RHSP is most commonly because of a bitemporal hemianopsia resulting from a compressive chiasmal lesion. RHSP is rare, although the exact incidence is unknown. Pituitary abscesses (PA) are uncommon and believed to account for 0.27%–0.6% of operated pituitary lesions (1,2). They may be primary, without any underlying cause in a previously healthy gland, or secondary, arising from pituitary lesions such as adenomas, Rathke cleft cysts, and craniopharyngiomas (3). We report a case of a patient who developed RHSP as a manifestation of pituitary abscess, 2 months after resection of a pituitary adenoma. To the best of our knowledge, this is the first such reported case in the English language, ophthalmic literature. A previously healthy 51-year-old woman presented with progressive weight gain, fatigue, and decreased visual acuity for 4 years. Her medical history was significant for hypothyroidism, diagnosed during her workup for weight gain and fatigue, anxiety, depression, and hearing loss. She had no ocular history. She was taking levothyroxine, zolpidem, and alprazolam. Her family and social histories were noncontributory. At the time of her initial workup, she was diagnosed with primary hypothyroidism and commenced on levothyroxine. She continued to have symptoms followed by progressive headache and intermittent binocular diplopia. She presented to ophthalmology and was noted to have a bitemporal hemianopsia on automated perimetry (automated visual fields 24-2), with a mean deviation of 211.46 dB in the left eye (OS) and 213.01 dB in the right eye (OD). Her prolactin was elevated to 76.4 ng/mL (normal 4.8–23.3 ng/mL). MRI of the brain demonstrated an intrasellar mass with suprasellar extension, compatible with pituitary macroadenoma with likely cavernous sinus invasion. She underwent resection of the lesion, with a postoperative course complicated by cerebrospinal fluid leak, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and subsequently diabetes insipidus (DI) managed with regular desmopressin. Histopathology was consistent with pituitary adenoma. Postoperative visual fields performed 2 months after resection revealed visual acuity 20/25 in both eyes (OU), and almost complete resolution of her bitemporal hemianopsia —mean deviation now 20.96 dB OS and 21.33 dB OD (Fig. 1). Department of Neurosurgery (LS, DSB), Houston Methodist Hospital, Houston, Texas; Department of Ophthalmology (SR, PWM, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Departments of Ophthalmology, Neurology, and Neurosurgery (AGL), Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa. The authors report no conflicts of interest. Address correspondence to Andrew G. Lee, MD, Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6560 Fannin Street, Ste 450, Houston, TX 77030; E-mail: aglee@ houstonmethodist.org Schwartz et al: J Neuro-Ophthalmol 2023; 43: e217-e218 FIG. 1. Automated perimetry (automated visual fields 24-2) 9 days before symptom onset showing very mild bitemporal hemianopsia (top) and then repeat visual fields when the patient is symptomatic (bottom) showing dense bitemporal hemianopsia. e217 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence Nine days after her follow-up ophthalmologic examination, she represented with new fevers, worsening binocular diplopia, and rapidly worsening bitemporal hemianopsia. Ophthalmologic examination revealed visual acuity of 20/ 30 OD and 20/40 OS. The pupils were isocoric with no relative afferent pupillary defect. Motility examination was full OU. Intraocular pressures, extraocular movements, slitlamp biomicroscopy, and dilated fundus examination were unremarkable. Automated visual fields 24-2 confirmed new bitemporal hemianopsia, with mean deviations now 214.72 dB OS and 213.07 dB OD (Fig. 1). Repeat MRI brain compared with a routine MRI brain 2 weeks prior demonstrated rapid interval changes, with a complex material within the sella and suprasellar region surrounded by an enhancing rim with significant mass effect on the optic chiasm consistent with pituitary abscess (Fig. 2). The patient started empirically on antibiotics and underwent emergent exploratory surgery. Immediately on entry into the sella, purulent material was encountered under pressure, which was debrided and washed out without complication. Postoperatively, the patient continued to have DI and require desmopressin. Her diplopia resolved, and she subjectively felt her vision had improved. Follow-up neuro-ophthalmic examination 2 weeks later showed visual acuity of 20/25 OD and 20/40 OS and improved bitemporal hemianopsia on humphrey visual fields (HVF) (mean deviation 20.96 dB OS and 21.33 dB OD). No ophthalmoplegia was noted. Optical coherence tomography showed band atrophy in both eyes, consistent with the bitemporal hemianopsia. Trans-sphenoidal surgery is recommended increasingly as the first-line surgical method of pituitary adenoma and abscess after transsphenoidal surgery is extremely rare. PA is presumed to be caused by hematogenous seeding or by direct extension of adjacent infection. Patients most commonly present with headache, panhypopituitarism, and visual disturbance, typically bitemporal hemianopsia or paretic diplopia from cavernous sinus involvement (4). Retrospective reviews of the literature regarding PA post- transsphenoidal surgery suggest that while 90% of patients will have a headache, only 40%–50% of the patients will have fever, visual impairment, or nausea/vomiting, making the diagnosis more challenging, and 21% of the cases had a preoperative incorrect presumed diagnosis, with clinicians provisionally diagnosing recurrence of the previous lesion because of nonspecific clinical and radiographic features (3). The causative organism is often only identified in w40% of cases (1). The pathological basis for RHSP relates to the links between the 2 hemifields in the retina. Previous analysis of the ganglion cell density of the central retina has identified a 0.2 mm vertical strip from which the ganglion cells project to both optic tracts. This overlapping layer allows for image fusion in binocular vision, and disruption of this area can lead to intermittent and variable binocular horizontal or vertical diplopia (5). The most common cause of diplopia from pituitary lesions relates to invasion of the cavernous sinus and cranial nerve involvement. To the best of our knowledge, this is the first reported case of RHSP in pituitary abscess in the English language ophthalmic literature. Clinicians should be aware that although rare, pituitary abscess should be considered in the differential diagnosis for a patient with headache, panhypopituitarism, and visual disturbances after a transsphenoidal approach to pituitary lesion, and the absence of fevers or typical MRI findings does not exclude the diagnosis. STATEMENT OF AUTHORSHIP Conception and design: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee; Acquisition of data: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee; Analysis and interpretation of data: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee. Drafting the manuscript: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee; Revising it for intellectual content: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee. Final approval of the completed manuscript: L. Schwartz, S. Raviskanthan, P. W. Mortensen, D. S. Baskin, A. G. Lee. REFERENCES FIG. 2. MRI of the brain with gadolinium contrast 9 days before hospitalization (A), and at time of hospital presentation (B) showing new rim enhancing lesion with significant mass effect on the optic chiasm consistent with pituitary abscess. e218 1. Wang L, Yao Y, Feng F, Deng K, Lian W, Li G, Wang R, Xing B. Pituitary abscess following transsphenoidal surgery: the experience of 12 cases from a single institution. Clin Neurol Neurosurg. 2014;124:66–71. 2. Jain KC, Varma A, Mahapatra AK. Pituitary abscess: a series of six cases. Br J Neurosurg. 1997;11:139–143. 3. Li Z, Yang C, Bao X, Yao Y, Feng M, Deng K, Liu X, Xing B, Wang R. 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