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Neurology

Bilateral Complete Ophthalmoplegia in a 50-Year-Old Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Neurology

Published Online: June 6, 2022

JAMA Neurology Clinical Challenge

Article Information and Disclosures

Nitika Arora, MBBS¹;

Jacqueline Leavitt, MD²;

John J. Chen, MD, PhD^2,3

Author Affiliations

¹Department of Ophthalmology, Mayo Clinic Health System, La Crosse, Wisconsin
²Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
³Department of Neurology, Mayo Clinic, Rochester, Minnesota

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A 50-year-old man was referred for ophthalmoplegia that developed immediately after an 8.5-hour robotic cystectomy for small cell cancer of the bladder. After recovering from anesthesia in the postanesthesia care unit, he experienced headache, facial numbness, inability to open both his eyes, and inability to move both eyes in any direction.

He had a known enhancing central skull base lesion in sella turcica with compression of the optic chiasm and mild mass effect on the pons that was felt to be a pituitary macroadenoma (Figure). His baseline examination before the cystectomy showed visual acuity of 20/20 OU with intact extraocular movements and unremarkable confrontational fields, although a mild bitemporal hemianopia was seen on automated visual fields.

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A 50-year-old man was referred for ophthalmoplegia that developed immediately after an 8.5-hour robotic cystectomy for small cell cancer of the bladder. After recovering from anesthesia in the postanesthesia care unit, he experienced headache, facial numbness, inability to open both his eyes, and inability to move both eyes in any direction.

He had a known enhancing central skull base lesion in sella turcica with compression of the optic chiasm and mild mass effect on the pons that was felt to be a pituitary macroadenoma (Figure). His baseline examination before the cystectomy showed visual acuity of 20/20 OU with intact extraocular movements and unremarkable confrontational fields, although a mild bitemporal hemianopia was seen on automated visual fields.

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Article Information

Corresponding Author: John J. Chen, MD, PhD, Department of Ophthalmology, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905 (chen.john@mayo.edu).

Published Online: June 6, 2022. doi:10.1001/jamaneurol.2022.1320

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Briet C , Salenave S , Bonneville JF , Laws ER , Chanson P . Pituitary apoplexy. Endocr Rev. 2015;36(6):622-645. doi:10.1210/er.2015-1042 PubMed Google Scholar Crossref

Möller-Goede DL , Brändle M , Landau K , Bernays RL , Schmid C . Pituitary apoplexy: re-evaluation of risk factors for bleeding into pituitary adenomas and impact on outcome. Eur J Endocrinol. 2011;164(1):37-43. doi:10.1530/EJE-10-0651 PubMed Google Scholar Crossref

Murad-Kejbou S , Eggenberger E . Pituitary apoplexy: evaluation, management, and prognosis. Curr Opin Ophthalmol. 2009;20(6):456-461. doi:10.1097/ICU.0b013e3283319061 PubMed Google Scholar Crossref

Boellis A , di Napoli A , Romano A , Bozzao A . Pituitary apoplexy: an update on clinical and imaging features. Insights Imaging. 2014;5(6):753-762. doi:10.1007/s13244-014-0362-0 PubMed Google Scholar Crossref

Semple PL , Jane JA , Lopes MB , Laws ER . Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J Neurosurg. 2008;108(5):909-915. doi:10.3171/JNS/2008/108/5/0909 PubMed Google Scholar Crossref

Bujawansa S , Thondam SK , Steele C , et al. Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom. Clin Endocrinol (Oxf). 2014;80(3):419-424. doi:10.1111/cen.12307 PubMed Google Scholar Crossref

Gruber A , Clayton J , Kumar S , Robertson I , Howlett TA , Mansell P . Pituitary apoplexy: retrospective review of 30 patients—is surgical intervention always necessary? Br J Neurosurg. 2006;20(6):379-385. doi:10.1080/02688690601046678 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.