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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

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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C. Pituitary apoplexy

Based on the acute presentation of symptoms and signs starting immediately after surgery and change in the appearance of tumor on MRI (loss of central enhancement), a diagnosis of pituitary apoplexy was made. The ophthalmoplegia in ocular motor apraxia can be overcome with vestibular ocular reflex, which was not the case here. The absence of exophthalmos and normal intraocular pressure argue against the diagnosis of orbital compartment syndrome. Imaging does not support the diagnosis of cavernous sinus thrombosis.

Pituitary apoplexy is an acute-onset syndrome due to hemorrhaging and/or infarction of the pituitary gland. Postoperative pituitary apoplexy has been reported after cardiac surgery, abdominal surgery, thyroidectomy, laparoscopic lumbar spinal fusion, and knee arthroplasty.1 Risk factors proposed during surgery that could lead to pituitary apoplexy include prolonged mechanical ventilation, embolization, unstable blood pressure, anticoagulation, crystalloid hemodilution, previous treatment with dopamine agonists, and radiotherapy.2

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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
1.
Briet  C , Salenave  S , Bonneville  JF , Laws  ER , Chanson  P .  Pituitary apoplexy.   Endocr Rev. 2015;36(6):622-645. doi:10.1210/er.2015-1042PubMedGoogle ScholarCrossref
2.
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-10-0651PubMedGoogle ScholarCrossref
3.
Murad-Kejbou  S , Eggenberger  E .  Pituitary apoplexy: evaluation, management, and prognosis.   Curr Opin Ophthalmol. 2009;20(6):456-461. doi:10.1097/ICU.0b013e3283319061PubMedGoogle ScholarCrossref
4.
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/s13244-014-0362-0PubMedGoogle ScholarCrossref
5.
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/2008/108/5/0909PubMedGoogle ScholarCrossref
6.
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.12307PubMedGoogle ScholarCrossref
7.
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:10.1080/02688690601046678PubMedGoogle ScholarCrossref
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