Late diagnosis of pituitary and parapituitary lesions causing visual failure.

It is well recognised that pituitary or parapituitary lesions may compress the optic chiasm, causing visual field defects and ultimatelyIn patients with unexplained visual impairment a ca optic atrophy and even blindness.Unfortunately, however, these endocrine history should be taken with formal plotti tumours are still occasionally missed entirely or diagnosed late, so visual fields, plain skull radiography, and, if indic that vision is less likely to recover.'We report on five patients seen computedtomography to exclude a lesion in the pitu during the past three years at this hospital in whom the delay between or parapituitary region initial presentation and correct diagnosis and referral was up to seven years; this was probably a factor in the persistence of visual impairment after treatment in some of the patients. Case reportsThe table shows the results of pituitary tests and tests of vision before and after treatment in all five patients.Case 1-A 69 year old man presented to the ophthalmology department of his local hospital in 1981 with blurred vision in his right eye.Central serous retinopathy was diagnosed.Although a right temporal scotoma was noted a year later, he was followed up clinically for a further 18 months, during which time his vision gradually deteriorated.Four years after the initial presentation formal visual field testing by Goldmann perimetry was performed because of further failure of vision; this showed upper bitemporal field defects, and he was referred for assessment.When seen in our unit because ofthis field defect and because by then a pituitary tumour was suspected he gave an additional history of impotence of 10 years' duration, lethargy of four years' duration, and dull pain behind his right eye.Examination showed that he was hypogonadal with thin, dry skin, and perimetry showed only small nasal fields of vision remaining.Computed tomography of the head confirmed the presence ofa large pituitary tumour with suprasellarextension, and endocrine assessment showed it to be a non-functioning adenoma; it was removed transsphenoidally with improvement both in his visual fields and in his visual acuity.Case 2-A 44 year old woman presented to her local hospital in 1979, having awoken with blurred vision in both eyes.Retrobulbar neuritis was diagnosed, and she was given a two year course of injections of adrenocorticotrophic hormone, which resulted in weight gain of32 kg but little improvement in her vision.In 1982 she was referred to our unit for a second opinion about the cause ofher obesity and visual loss.When seen she also gave a history ofabrupt cessation of menstruation nine years previously, when she was 35, and a four year history oflethargy and intermittent headaches.Examination showed that she was almost blind, with bilateral optic atrophy.Goldmann perimetry showed sparing ofonly the left and right nasal fields.Her visual acuity was 6/0 bilaterally.In addition she had mild galactorrhoea.Computed tomography showed a large suprasellar enhancing mass.Endocrine investigations showed hyperprolactinaemia (prolactin concentration 2871 mU/l), pituitary depend-