Chiasmal herniation as a complication of bromocriptine therapy.
BACKGROUND
Medical treatment of macroprolactinomas with dopamine agonists decreases tumor mass and improves visual defects. We report an unusual complication of a macroprolactinoma responding to bromocriptine: a visual field defect caused by downward herniation of the optic chiasm.


METHODS
A 64-year-old woman was found to have a 4.5 cm macroprolactinoma with superior displacement of the optic chiasm, bitemporal hemianopia, and serum prolactin concentration (P) of 17,060 micrograms/L. Bromocriptine was initiated at 2.5 mg/day and increased to 7.5 mg/day over 2 months.


RESULTS
After 2 months, visual fields improved significantly and tumor height decreased to 3 cm with resolution of the optic chiasm displacement. P decreased to 1,180 micrograms/L. After 5 months of therapy, visual fields were normal, and P was 8 micrograms/L. After 8 months of therapy, new bilateral visual defects were observed. Magnetic resonance imaging (MRI) revealed further decrease of the tumor height to 1.5 cm, and inferior and leftward traction of the optic chiasm as the probable mechanism for the new visual field deficit. P was < 1 microgram/L. Bromocriptine was decreased to 5 mg/day to allow reduced traction on the optic chiasm and its blood supply. Over the next 4 months, visual field abnormalities resolved.


CONCLUSIONS
We report the development of a visual field abnormally that is explained by chiasmal herniation caused by a shrinking macroprolactinoma. This complication resolved with a decrease in the bromocriptine dose. We suggest that patients undergoing bromocriptine therapy for macroprolactinomas be followed for this potential complication.
Taxel
P
P
Department of Medicine, University of Connecticut Health Center, Farmington 06030-1110, USA.
Waitzman
D M
DM
Harrington
J F
JF
Fagan
R H
RH
Rothfield
N F
NF
Chen
H H
HH
Malchoff
C D
CD
D001971:Bromocriptine / Q000009:adverse effects* / Q000627:therapeutic use; D003389:Cranial Nerve Diseases / Q000139:chemically induced* / Q000175:diagnosis; D018491:Dopamine Agonists / Q000009:adverse effects* / Q000627:therapeutic use; D004677:Encephalocele / Q000139:chemically induced* / Q000175:diagnosis; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009897:Optic Chiasm / Q000002:abnormalities / Q000187:drug effects* / Q000473:pathology; D010911:Pituitary Neoplasms / Q000188:drug therapy* / Q000473:pathology; D015175:Prolactinoma / Q000188:drug therapy* / Q000473:pathology; D014786:Vision Disorders / Q000175:diagnosis / Q000209:etiology; D014794:Visual Fields
D018491:Dopamine Agonists; D001971:Bromocriptine