Secondary deterioration of visual field during cabergoline treatment for macroprolactinoma.

OBJECTIVE: During dopaminergic agonist treatment for macroprolactinoma, tumour shrinkage can be accompanied by secondary deterioration of the visual field in rare instances. The aim of the present study was to evaluate the incidence of symptomatic or asymptomatic delayed visual loss associated with chiasmal herniation during long-term cabergoline treatment of macroprolactinomas and to report our experience of its management. PATIENTS: The study included 28 patients (11 women and 17 men) aged 14-85 years treated for macroprolactinoma with cabergoline at our centre from 1997 to 2006. RESULTS: Chiasmal herniation was observed at MRI in five out of the 28 cases. A systematic visual field evaluation revealed visual field worsening, during cabergoline treatment, in three out of these five patients. In two asymptomatic patients, secondary deterioration of visual field occurred 2.5 years and 4 years, respectively, after cabergoline treatment initiation. In the third case, cabergoline treatment resulted in a paradoxical worsening of an initial visual defect. In all three cases, visual fields improved after cabergoline withdrawal although chiasmal herniation persisted. Visual field remained normal in the two other patients. CONCLUSIONS: Our results suggested that chiasmal herniation associated with delayed visual field defect is not a rare feature during cabergoline treatment of macroprolactinomas. It should be assessed by systematic visual field evaluation and treated by adaptation of medical treatment.

Predicting visual outcome after treatment of pituitary adenomas with optical coherence tomography.

PURPOSE: To evaluate if optical coherence tomography (OCT), by providing an objective measure of the retinal nerve fiber layer (RNFL) thickness, offers a reliable prediction of visual outcome. DESIGN: Prospective cohort study. METHODS: Thirty-seven eyes of 19 consecutive patients from a single hospital suffering from pituitary adenomas compressing the anterior visual pathways were included, and compared with 46 eyes of 23 controls. Exclusion criteria included any previous treatment of pituitary adenoma and high myopia. Seventeen patients underwent trans-sphenoidal surgery and two patients with macroprolactinomas received dopamine agonists. Automated visual fields (VF) and OCT (fast-RNFL program) were performed before treatment, and two weeks and three months after treatment. RESULTS: Among the eyes with a VF defect before treatment, the odds of complete recovery after three months from the initial VF defect was multiplied by 1.29 for each increase by 1 micron of mean RNFL (odds ratio [OR], 1.29; P = .037). This was independent from age and duration of symptoms, which carried their own prognostic value. Inferior RNFL was a very strong prognostic factor; OR, 6.31 per micron (P = .0000). CONCLUSION: RNFL thinning measured by OCT puts the patient at decreased chance of recovery of an initial VF defect three months after treatment in pituitary adenomas compressing the anterior visual pathways. Further studies will establish how useful this tool is for long-term visual outcome.

Spontaneous resolution of a Meckel's cave arachnoid cyst causing sixth cranial nerve palsy.

A 32-year-old pregnant woman developed a progressive right sixth cranial nerve palsy as an isolated finding. Brain MRI disclosed a discrete lobulated lesion centered in the right Meckel's cave with intermediate signal on T1, high signal on T2, and diffusion characteristics similar to those of cerebrospinal fluid on apparent diffusion coefficient mapping. The initial radiologic diagnosis was schwannoma or meningioma. No intervention occurred. Shortly after cesarean delivery, the abduction deficit began to lessen spontaneously. One month later, the abduction deficit had further improved; 7 months later it had completely resolved. Repeat MRI after delivery failed to disclose the lesion, which was now interpreted as consistent with an arachnoid cyst arising within Meckel's cave. Twenty-one similar cases of Meckel's cave arachnoid cyst or meningocele have been reported, 7 found incidentally and 14 causing symptoms, 2 of which produced ipsilateral sixth cranial nerve palsies. All previously reported symptomatic patients were treated surgically. This is the first report of an arachnoid cyst arising from Meckel's cave in pregnancy and having spontaneous resolution.

Prevalence of papilloedema in patients with sleep apnoea syndrome: a prospective study.

The association of papilloedema (PO) with respiratory diseases and especially obstructive sleep apnoea (OSA) syndrome has been emphasised in many reports. The pathophysiology could rely on the episodic increase of intracranial pressure related to apnoeic episodes during night sleep. Nevertheless, prevalence of papilloedema in patient with OSA syndrome remains unknown. As this information could improve diagnosis and therapeutic strategies, the aim of the present study was to investigate the prevalence of PO in an OSA syndrome population. From 95 successive, recently diagnosed OSA patients, 35 answered a questionnaire about visual symptoms and underwent fundoscopic examination. Visual symptoms suggestive of PO were present in 40% of the patients, but none had PO. As a conclusion, PO does not seem to be frequently associated with OSA syndrome and systematic screening of PO in these patients does not seem to be warranted. Nevertheless, patients with visual complaints evocative of papilloedema should have their eye fundus checked since the association between OSA and PO exists. Further studies, including more patients, might be useful to establish which patients are at particular risk for this complication.