When atypical becomes urgent: Unleashing the ophthalmologist's role in managing unconventional macroadenomas

Abstract

Aims/Purpose: To present an atypical macroadenoma case and its management, in which the visual monitoring was key to indicate surgical intervention.Methods: Case report.Results: A 55‐year‐old male who was admitted to our emergency department with a main complaint of bilateral central and painless visual loss of 2 days' duration. He had DM type II. BCVA OU was 0.2, with no RAPD, but bilateral dyschromatopsia (OD: 4/16 OS: 10/16). Computerized visual field testing revealed a central scotoma (OD) and temporal hemifield loss (OS). An urgent CT scan revealed the presence of a 24 × 15 × 3 mm sellar‐suprasellar mass, with a locoregional mass effect and possible extension to cavernous sinuses and optic chiasm compression. 12 h after admission, deterioration of BCVA was observed (OD: 0.05 and OS: 0.1), along with worsening of dyschromatopsia (OD: 2/16 and OS: 7/16) and campimetric deficit progression (left homonymous hemianopic pattern). The MRI revealed the presence of a 21 × 21 × 36 mm sellar mass, without signs of recent intratumoral bleeding, with solid suprasellar extension, posterior cystic degeneration, compressing optic nerve, right optic tract, optic chiasm, and invading right cavernous sinus. Due to the worsening visual function, a consensus decision was made to proceed with same‐day endoscopic transsphenoidal resection. 24 h post‐surgery, the patient showed improvement in BCVA (1.0 OU) and dyschromatopsia (OD: 10/16 and OS: 12/16).Conclusions: In our case, despite unclear compressive effect on neuroimaging, careful monitoring of visual function allowed to timely indicate surgery, as the positive outcomes reflect. Managing this pathology in tertiary hospitals goes beyond the required experience of the neurosurgical team. The time for surgery indication is a big challenge due to the lack of clear definitions to indicate surgical intervention: “impending vision loss” or “clinically significant increase in size near the visual pathway.”