What is the recommended physical exam for a suspected pituitary adenoma?

Physical Examination for Suspected Pituitary Adenoma

For patients with suspected pituitary adenoma, a comprehensive ophthalmologic evaluation is strongly recommended, including visual acuity testing (ideally using logarithm of the minimum angle of resolution measurement), visual field testing (preferably Goldmann perimetry), and fundoscopy. 1

Ophthalmologic Examination Components

• Visual acuity assessment using quantitative measures (logarithm of the minimum angle of resolution) rather than qualitative measures to detect subtle changes 1
• Visual field testing, preferably using Goldmann perimetry or automated static perimetry, which can detect subtle bitemporal visual field defects that patients may be unaware of 1
• Fundoscopy to assess for optic nerve integrity and detect optic atrophy 1
• Color vision testing may be included as part of the comprehensive ophthalmologic evaluation 1
• Consider baseline optical coherence tomography (OCT) in patients with confirmed pituitary adenoma who have potentially severe acuity or field deficits 1

Rationale for Ophthalmologic Examination

• Pituitary macroadenomas can impinge on the optic chiasm and optic nerves, causing visual disturbances 1
• Visual disturbances are more common in pediatric patients with pituitary adenomas than in adults 1
• Ophthalmologic evaluation can identify patients with asymptomatic visual deficits 1
• Preoperative ophthalmologic assessment provides baseline measurements for comparison with postoperative evaluations 1
• OCT can serve as a surrogate for visual field loss and visual dysfunction, as a thinner retinal nerve fiber layer is present in patients with visual field loss 1

Timing of Visual Assessment

• For patients with confirmed pituitary macroadenoma, consider follow-up visual assessment (including acuity and fields if age-appropriate) within 3 months of first-line therapy 1
• Ongoing visual follow-up should be based on individual indications 1

Prognostic Considerations

• Older patients and those with longer duration (>4 months) of vision loss should be counseled regarding reduced chance of postoperative vision improvement 1
• Early detection of visual field deficits is important, as many patients may be unaware of them 1

Additional Evaluations

• All patients with pituitary tumors require endocrine evaluation for hormone hypersecretion 2
• Patients with macroadenomas additionally require evaluation for hypopituitarism 2
• Neuroimaging with dedicated pituitary MRI protocol is essential, including pre-contrast (T1 and T2) and post-contrast-enhanced (T1) thin-sliced sequences 1, 3
• Consider 3-Tesla MRI for surgical planning as it enhances anatomical definition 1, 3

Clinical Pitfalls and Caveats

• Visual acuity measurement requires patient cooperation and attention; use age-specific tests when appropriate 1
• Visual field defects may be present even when patients are asymptomatic 1
• The characteristic visual field defect caused by pituitary adenomas with suprasellar extension is bitemporal hemianopsia 4
• There is a linear correlation between visual field defects and chiasmal compression 4
• Non-functioning pituitary adenomas may present with more severe visual field defects compared to functioning adenomas 4