Discovery of a large Pituitary macroadenoma on evaluation of a patient with Pars Planitis The authors have no financial interest in the subject matter of this poster

Purpose  We report a case of a patient who was referred for evaluation and treatment of an 11year history of pars planitis.  The patient recently had a history of headaches  Ophthalmologic exam revealed elevated discs and vitreous cells.  An investigation revealed a large enhancing sellar mass compatible with a pituitary macroadenoma.

INTRODUCTION  Pars planitis is an idiopathic clinical entity with bilateral intermediate uveitis 1  In addition to aggregates in the inferior pars plana (snowbanking), vitritis and CME, optic nerve head swelling can be one of the ocular manifestations 1  The ocular symptoms are compatible with those seen in uveitis such as red eye, pain and photophobia 1. However, intractible posterior headaches is an unusual presentation for a patient with pars planitis.

INTRODUCTION  Pituitary tumors can be grouped into non- secreting and secreting types 2.  Tumors of the non-secreting types more often present with loss of vision while the secreting type more often present with endocrine dysfunction 2.  The presence of headache in pituitary tumor is due to a combination of factors, including intrasellar pressure, tumor extension, relationship with the sellar structures, patient predisposition, and functional disturbance within the hypothalamo-pituitary axis 3.

CASE REPORT  A 28 year old African American male was referred for evaluation.  He had a history of Pars planitis from ages 11 to 22. Due to inadequate insurance coverage, he had not followed up with his ophthalmologist for 6 yrs.  For the past year, the patient had developed posterior headaches and decreased vision in the right eye which prompted him to seek out medical care.  On presentation to his Ophthalmologist’s office he was noted to have elevated optic discs, vitreous cells and a decreased best corrected visual acuity. He was then referred for further evaluation and treatment

CASE REPORT  On physical examination, the patient’s VA was: 20/50 OD, 20/25 OS  EOM, pupils and IOPs were all within normal.  Color plates were diminished on the left.  Slit Lamp Exam revealed fine keratic precipitates OD. 1+ cell/flare OD, Trace cells/flare OS.  Dilated fundus exam revealed vitreous cells, significant disc elevation OU and cystoid macular edema OD  Snowbanking of the retina was also present on examination OD

RESULTS The Patient was started on Durezol OU and Nevanac OD. A systemic work-up was undertaken which included a CBC, RPR, FTA-ABS, ACE levels, lyme titers and an MRI of the brain/orbits with and without contrast. A referral to the retina service was also put in place

RESULTS  The blood work revealed negative results,  MRI of the brain revealed an enhancing sellar mass measuring 31x34x24mm. The optic chiasm was compressed and displaced upwardly. The mass also extended laterally to the carotid arteries and cavernous sinus. Based on imaging characteristics it was believed to be a pituitary macroadenoma.

RESULTS  The patient was sent to a neuroophthalmologist for evaluation. On visual field testing, he was noted to have a significant bitemporal field defect which he was previously unaware of.  He underwent a transphenoidal excision of the mass  Subsequently, he recovered most of his visual field defect. The patient's vision also significanty improved after the treatment of his cystoid macula edema

RESULTS T1 weighted post-contrast image through the sella.

RESULTS Visual Field Pre-op Visual Field Post-op

DISCUSSION  Pars planitis is an idiopathic clinical entity with bilateral intermediate uveitis. It is typically seen in young adults and children 1.  It can have many variable presentations including, vitreous hemorrhage due to peripheral neovascularization 4, 1.  Neovascularization of the disc has also been reported in patients with pars planitis 5.  The disease can be chronic or self-limited 1.

DISCUSSION Recurrences respond well to steroids. The Prognosis is usually good if the patient’s disease is not complicated by CME or posterior subcapsular cataracts. Pars plana vitrectomy may be an option for complications such as retinal detachments 1. A common complaint at presentation could be decreased vision due to uveitis or CME. However, headaches are not typically a presenting symptom of pars planitis

DISCUSSION  In about 75% of the cases, pituitary adenomas have hormonal abnormalities. In contrast, the non- hormonally active lesions become symptomatic due to their size. Resulting in headache, visual abnormalities such as a bitemporal hemianopsia. Cranial nerve palsies, CSF rhinorrhea have also been reported as presenting symptoms 6.  These lesions even with extention into the suprasellar space can be removed transsphenoidal ly. Giant adenomas are best controlled with craniotomy and/or a combined, transphenoidal and transcranial route 7.

CONCLUSION This case highlights the importance of a systemic work-up in patients who present with new symptoms, despite already having a diagnosis that explains some of the signs on exam. More than one pathology may be present in a patient with an already existing condition.

REFERENCES 1 Retina and Vitreous. Basic and Clinical Science Course ; Neuro-Ophthalmology. Basic and Clinical Science Course ; Headache associated with pituitary tumors. J Headache Pain Feb; 10(1): Pars Planitis presenting with vitreous hemorrhage. Ophthalmic Surg Sep;24(9): Neovascularization of the disc in Pars Planitis. Retina. 1990; 10(4): Grossman RI, Yousem DM. Neuroradiology. 2 nd ed. Philadelphia: Mosby; 2003; Combined endoscopic transsphenoidal-transventricular approach for resection of a giant pituitary macroadenoma. World Neurosurgery. 2010;74(1):161-4

Thanks  Special thanks to:  David Wagner, MD  Benjamin Osborne, MD  Josef Tamory, COMT  Jay Lustbader, MD