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.