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Ipilimumab is an immunotherapeutic agent used in the treatment of metastatic melanoma, and is known to cause hypophysitis in some patients. Magnetic resonance imaging of ipilimumab-induced hypophysitis typically shows diffuse enlargement of the pituitary gland with variable enhancement or enlargement of the infundibulum. This often produces a diagnostic dilemma as melanoma not uncommonly metastasizes to the pituitary gland due to the rich vascular plexus of the hypophyseal portal system, and has a similar imaging appearance to autoimmune hypophysitis. We present a case of a 49-year-old man with a Clark level 4 melanoma of the left calf with inguinal nodal metastases that was treated with resection and 2 cycles of ipilimumab, and subsequently developed a “cystic” pituitary mass. To our knowledge, all of the described cases of ipilimumab-induced hypophysitis to date have shown solid enhancement on imaging. Because metastatic melanoma to the pituitary gland often has internal hemorrhage that produces a “cystic” appearance, and ipilimumab-induced hypophysitis is typically a solidly enhancing abnormality, this presented a significant diagnostic and therapeutic dilemma. Our patient's symptoms, although significant, did not necessitate immediate surgical intervention, and a conservative approach of withholding the ipilimumab and administering therapeutic corticosteroids was pursued. The patient's symptoms abated and follow-up magnetic resonance imaging 1 month later showed near complete resolution of the pituitary abnormalities. As such, this is a unique case of ipilimumab-induced hypophysitis presenting as a “cystic” pituitary mass. Keywords: Hypophysitis, Ipilimumab, Pituitary mass, Pituitary inflammation

Background: A majority of multiple sclerosis patients experience visual impairment, often as the initial presenting symptom of the disease. While structural changes in the retinal nerve fiber layer and optic nerve have demonstrated correlations with brain atrophy in multiple sclerosis using magnetic resonance imaging, a non-invasive, cost-effective, and clinically efficacious modality to identify early damage and facilitate prompt therapeutic intervention to slow the progression of multiple sclerosis and its ocular manifestations, is still urgently needed. In this study, we sought to determine the role of macular sensitivity measured by microperimetry in the detection of subclinical multiple sclerosis-related retinal damage and visual dysfunction., Methods: This cross-sectional observational case-control study involved population-based samples of multiple sclerosis patients and age-, race-, and gender-matched healthy control subjects. Among the key criteria for the multiple sclerosis patients were diagnosis by the McDonald criteria, visual acuity greater than 20/25, and no history of optic neuritis. Macular sensitivity and average macular thickness were measured in all subjects using microperimetry and spectral-domain optical coherence tomography, respectively. Pearson correlation coefficients were measured using bivariate correlations. Sample means, mean differences, and 95% confidence intervals were calculated using independent sample t-tests., Results: Twenty-eight eyes from 14 MS patients and 18 eyes from 9 control subjects were included. Mean macular sensitivity of control subjects and multiple sclerosis patients in decibels was 18.2 ± 0.4 and 16.5 ± 0.4, respectively, corresponding to a mean difference of 1.7 (95% CI, 1.1-2.4; P < 0.001). Macular sensitivity was positively correlated with macular thickness in multiple sclerosis patients (r = 0.49, P = 0.01) but not control subjects (r = 0.15, P = 0.55)., Conclusions: Macular sensitivity as measured by microperimetry was decreased in multiple sclerosis patients with normal visual acuity and no history of optic neuritis. Furthermore, macular sensitivity demonstrated a positive correlation with macular thickness as measured by optical coherence tomography. As such, microperimetry may represent a non-invasive and efficient method to identify signs of subclinical visual dysfunction that correspond with early macular architectural changes characteristic of multiple sclerosis.

Background: There is uncertainty as to whether spasmus nutans (SN) is an isolated idiopathic entity or whether there are underlying conditions that could cause or be associated with the nystagmus. We undertook this study to determine the frequency of ocular, intracranial, and systemic conditions in patients with nystagmus having characteristics of SN., Methods: We performed a chart review of 22 consecutive patients examined from 2000 through 2005 at the Dean McGee Eye Institute and Children' Hospital of Oklahoma with nystagmus consistent with SN. We collected information related to gender, age at presentation and age at final visit, visual acuity, refractive error, laterality of nystagmus, presence of head nodding and torticollis, pattern of strabismus, neuroimaging and electroretinography results, and other associated clinical findings., Results: Visual acuity was reduced in 75% of eyes at presentation and 58% of eyes at last visit. Eight patients had significant refractive error. Seven patients had strabismus. Two patients had chiasmal gliomas. Four patients had cone or rod/cone dystrophy. Only three patients had no associated ocular, intracranial, or systemic conditions., Conclusions: A substantial proportion of patients presenting with SN-like nystagmus have important underlying ocular, intracranial, or systemic abnormalities that may require evaluation and management.