Ocular Motor Dysfunction Versus Visual Impairment: A Two-Patient Case Series of Pituitary Macroadenoma Presentations

Abstract

Patients with pituitary macroadenoma typically present to ophthalmic clinics with visual field defects or optic disc pallor. Ocular motor symptoms such as diplopia, strabismus, and cranial nerve palsies due to parasellar or cavernous sinus invasion are often missed and may be the initial presentation. We present two patients who were examined in an ophthalmology outpatient clinic and diagnosed with pituitary macroadenoma with neuro-ophthalmologic findings. The first case was a 26-year-old female presenting with persistent headache, right esotropia, and decreased abduction of the right eye more than the left eye, with a history of infertility evaluated gynecologically. Laboratory tests and magnetic resonance imaging confirmed the diagnosis. The second patient was a 58-year-old man who had one month of reduced vision and headaches. Visual acuity was 0.1 in both eyes with slightly pale optic disks and limited abduction of the right eye with diplopia on right gaze. Automated perimetry, endocrine studies, and brain MRI confirmed the diagnosis of a pituitary macroadenoma. Both patients were referred for neurosurgical evaluation and continued to be followed up on cabergoline 0.5 mg as per the plan of their medical team. These cases illustrate the importance of considering pituitary macroadenoma in patients with unexplained esotropia, abduction deficits, diplopia, headaches, visual loss, optic disc pallor, or reproductive problems and highlight the need for a comprehensive neuro-ophthalmic evaluation, formal visual field testing, endocrine investigation, and contrast-enhanced sellar MRI in a multidisciplinary setting. They also emphasize that cabergoline should only be prescribed for proven hyperprolactinemia or prolactinoma and not based on tumor size alone.