CASE PRESENTATION
An 81-year-old blind male in both eyes presented for psychiatric evaluation with a three-year history of the on-and-off visual experience of seeing various images and shapes others could not see.
The visual experience coincided with the recurrence of a pituitary macroadenoma, about which the Trans-Sphenoidal Adenomectomy procedure was done fifteen years earlier. The onset of symptoms was preceded by progressive worsening of vision, followed by the sudden appearance and disappearance of various images ranging from elementary simple geometric shapes to well-formed complex “human-like figures.
Within a year, the visual experiences became more apparent, with the human-like figure suddenly appearing, walking alongside in female clothes and shapes before they disappeared abruptly. The humanoid-like creatures manifested in various forms, having distinct faces and extreme sizes of miniature and tall statures, and also displayed ”strange behaviour”, such as reading books and offering him money. The visual experience became more diverse involving scenery of both inanimate and animate objects, such as the sudden appearance of food plates and the view of a village full of huts and people of different sizes. Other experiences included sights of river banks with fast-flowing water bodies with swans swimming and playing; he also saw disfigured creatures with “cow-like faces” spontaneously changing their shapes. He reports his typical day begins with ”rays of sunlight passing through the curtains”, followed by seeing the scenery of animate or inanimate objects throughout the day until night when he goes to sleep.
Although the experiences sometimes felt intrusive and distressing, the patient held that the phenomena were “not real” and did not interact with the hallucinations. Further interviewing revealed no history of other types of psychotic experiences, depressive or anxiety symptoms.
During the interview in the doctor’s office, he reported seeing “a cloudy day, while sat on a chair in an open space on a floor full of white and green leaves” and “small and large artificial plastic trees arranged in a line, some of which were moving.
Past medical history was positive for pituitary macroadenoma fifteen years earlier, which began with a severe headache accompanied by progressive visual impairment. The previous Brain MRI scan showed a large lobulated sellar-suprasellar mass measuring 3.8cm by 3.3cm by 3.1cm in size; the optic chiasm stretched and compressed superiorly, revealing signs of secondary optic atrophy. Hormonal levels (Thyroid Stimulating Hormone, Triiodothyroxine (T3), Tretraiodothyroxine (T4), Prolactin and Growth Hormone) were within normal range.
Trans-sphenoidal excision of the pituitary tumour was done: Post-operative CT showed a blood clot with the empty sella with no tumour enhancement. Histopathology results confirmed pituitary adenoma.
There was some improvement in vision during discharge, his left vision was close to normal, and his right eye showed marginal improvement.
During the index assessment, neurological examination showed all cranial nerves were intact except for the optic never, where he had a visual acuity of total blindness with no response to light. Motor –bulkiness, tone and power were normal. Deep and superficial reflexes were intact; Babinski sign was negative and had normal sensations for touch, pain, vibration and proprioception. He displayed no gait abnormality, and there were no cerebellar signs.