Synopsis
Recognise optic chiasm and hormonal consequences of a sellar mass, prioritise cortisol and vision, and sequence MRI, formal perimetry, endocrine classification and specialist treatment safely.
- A sellar mass may present through visual loss, headache, cranial nerve palsy, hormone excess, pituitary deficiency or incidental imaging; size alone does not establish clinical significance.
- Upward expansion compresses the optic chiasm classically causing bitemporal field loss, but junctional, asymmetric or central defects occur and patients may not notice gradual peripheral change.
- New or progressive visual acuity loss, field deterioration, diplopia or reduced consciousness requires urgent pituitary, ophthalmology and neurosurgical assessment rather than routine clinic surveillance.
Key red flags
Thunderclap headache with visual loss, ophthalmoplegia, meningism or altered consciousness suggests pituitary apoplexy and requires immediate emergency management.
Investigation priorities
Define lesion compartment, optic relationship, cavernous extension, haemorrhage and differential morphology.
Management branches
Visual field, acuity, colour or ocular-motor change suggests optic or cavernous compression.
- Document bedside acuity, pupils, fields, colour and eye movements, and ask specifically about sudden headache or altered consciousness.
- Check haemodynamics, glucose, sodium and urgent cortisol status, giving emergency hydrocortisone if apoplexy or adrenal failure is plausible.
Key medicines
Hydrocortisone for central adrenal insufficiencyUse a physiological divided oral replacement regimen when stable, or immediate parenteral stress dosing when apoplexy, shock or failed absorption is suspected.
CabergolineBegin the pituitary specialist's low weekly regimen with food and titrate against prolactin, visual recovery, tumour size and tolerability.