Improvement of ophthalmological symptoms after surgical treatment in patients with pituitary apoplexy: a case series

Visual field defects and ophthalmoplegia can occur when pituitary apoplexy (PA) suprasellarly extends and exerts pressure (mass effect) on the optic chiasm or nerves, which requires immediate surgical intervention. Acute PA is associated with a delay, either in patient referral or hospital transport, between symptom onset and transsphenoidal surgery. Immediate transsphenoidal surgery is highly recommended for PA patients with visual impairment, irrespective of symptom onset, given the clear surgical benefits. Nevertheless, PA must be part of the differential diagnosis of patients presenting with persistent neurologic symptoms, particularly visual field defects. We report two male patients who presented with severe headache and visual symptoms. The first patient was a 34-year-old man with a history of occasional frontal headaches, and the second was a 47-year-old man with no previous history of headache who developed frontal and retro-orbital pain beginning 10 days before presentation. Associated symptoms included nausea, vomiting, diplopia, photophobia, and visual impairment. Brain magnetic resonance imaging (MRI) findings were consistent with pituitary apoplexy, and both patients underwent surgical treatment. Following surgery, headache, diplopia, and visual impairment improved. Both patients were of Persian ethnicity. Despite the availability of various guidelines for the management of PA, the optimal therapeutic approach remains controversial. The choice between conservative and surgical management, as well as the timing of surgery, should be individualized according to the patient's clinical presentation and severity of visual and neurological impairment. This case report demonstrates that acute headache accompanied by visual disturbances can represent the clinical manifestation of pituitary apoplexy, a neuroendocrine emergency that requires prompt evaluation. Our findings emphasize that timely diagnosis and appropriate surgical intervention may play a decisive role in improving visual outcomes and reducing long-term complications. Our experience with these two patients indicates that even in cases of initial delay in referral, targeted surgical management may lead to substantial recovery of visual function. Increasing clinical awareness of this condition can facilitate earlier diagnosis and more accurate therapeutic decision-making, as well as improved clinical outcomes for patients.