An Illawarra optometrist who detected a pituitary tumour, leading to an urgent diagnosis and surgery that saved the patient’s life, highlights the importance of listening to the patient, especially when they dismiss general health complaints as ‘unrelated’.
Mr Surendran (Suren) Naidoo from Specsavers Dapto was recently awarded Specsavers’ Dame Mary Perkins Award after a visual field test found a patient had a bitemporal hemianopia, a classic sign of pituitary tumour.
The award, introduced in 2021, is reserved for an optometrist within the network that has shown an exceptional act of patient care in the past 12 months – something Naidoo exhibited in spades when Mrs Kelly Pabis came to see him with a vision complaint.
Pabis, a mother with two children – one with special needs – and a partner, had been to Specsavers Dapto a few months prior but there was nothing obvious or unusual about her presentation.
“Her primary complaint at the time was mild double vision but I was not the optometrist that saw Kelly when she initially presented,” Naidoo says.
“I picked up the consultation three months later when she returned, saying that she felt something wasn’t quite right with her vision and that her eyes weren’t working together. She didn’t mention it to me, but she told a staff member at reception that she missed a car in her visual field while driving. At the time she came to see me, she wasn’t experiencing any double vision.”
After initial testing failed to provide a plausible explanation, Naidoo conducted a visual field test.
“I picked up what was very obviously a bitemporal hemianopia, but it was quite severe, it had crossed the midline and spread over to the other half. And there were quite a few errors on the visual field test,” he says.
“I said to her, ‘There are quite a few errors. I want to repeat the visual field test as soon as possible’. And she said, ‘Maybe I can come back in a couple of weeks’, but I told her this could potentially be more urgent than that.”
Pabis returned the following morning. This time, the visual fields reliability was better. A bitemporal hemianopia was more clearly defined and demarcated. Now, Naidoo faced a dilemma.
“You don’t want to scare the patient. I was very reluctant to tell her what I thought it was. But obviously I had to express the urgency of her situation, so I said to her ‘I’m hesitant to tell you what I suspect it is because it is not my area of expertise/speciality, but this has all the hallmarks and signs of a tumour of the pituitary gland’.”
He then questioned her further about other systemic symptoms and referred her to her GP with an urgent request for an MRI. To further complicate matters, the Specsavers Dapto store was about to close for three weeks for a planned expansion.
“During that time, we would have limited access to clinical records because we’d be working off site. I called Kelly and said, ‘We are closing for three weeks, and I’m particularly concerned about you. Have you seen your doctor yet? Because this is quite urgent’. She said ‘Well, actually,’ – she was very groggy when she spoke to me – ‘I’ve just come out of surgery’,” Naidoo recalls.
This was because – the day after seeing Naidoo – Pabis had an MRI and CT scan, returned home, and then received a call from Wollongong Hospital asking her to pack a bag and come immediately.
CT scan confirms tumour
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Naidoo has diagnosed serious conditions before, but not in Australia.
“I’ve lived and practised in a few countries. In England, we had a girl with an optic nerve tumour, which in that particular case was potentially life threatening. I have detected a couple of pituitary tumours in my time, but nothing in Australia until now,” he says.
Naidoo says Pabis’ CT scans (pictured above) revealed the tumour was about 2-2.5 times the size of an eye.
“It was, by my estimate, about five to seven centimetres in diameter, and it was very obvious on the scan that it had started bleeding into the sinuses, and that was why she started getting vision-related symptoms.”
Pabis had been experiencing other symptoms for years but never thought to mention them during an eye test, because she didn’t think it was related to her eyesight, Naidoo says.
“She never mentioned the cortisone injections she was getting for joint pain,” he explains.
“According to Kelly, she had been seeing her GP since 2018, complaining of joint pains. The GP eventually diagnosed her with tendinitis. After doing multiple blood tests, they gave her cortisone injections every three months into her hands, elbows and feet just to keep the pain away because she had trouble walking and using her hands.”
It highlights the importance of taking a patient’s history, but also the delicacy in asking certain questions that might draw out pertinent information.
“I ask patients if they have any health issues, and if they say no, I’ll usually ask them if they have any other symptoms they can think of that they don’t think maybe related to their eyes. Because I find that very often patients are experiencing systemic symptoms, but they don’t think about it when you ask them,” Naidoo says.
“For example, I ask if they are taking any other medication, if they have any other symptoms they haven’t mentioned. And they’ll say, ‘I don’t think my eyes have anything to do with that’. Some patients can get quite offended and aggressive, wondering why I’m asking these questions, thinking it’s got nothing to do with their eyes.”
Naidoo says that after surgery, Pabis said she felt numb, meaning the absence of aches and pains that had plagued her.
“All those pains in her joints and extremities vanished. It was only at the three-month check-up when everything was stable that the neurologist said to Kelly, ‘When you walked in, I had no idea how you were still alive’. Her tumour was that severe. Subsequently, Kelly came back to see me a few months later and we repeated her tests. Her vision, in terms of her prescription, hasn’t changed very much but the bitemporal hemianopia has completely disappeared and her visual field is completely restored,” Naidoo says.
“That I found amazing because I’ve seen patients where it doesn’t come back.”
His astute observations in Pabis’ case is something that comes with experience.
“It’s a lesson to not just myself but other optometrists and even student optometrists that the case history never stops. After the patient comes in, it continues through the entire consultation and sometimes even subsequent consultations,” Naidoo says.
“I remember a lecturer of mine all those years ago telling us at university that when the patient walks into a room, nine out of 10 times they will indirectly tell you what’s wrong with them. You just need to listen.”
The patient
Pabis can easily recall the sequence of events that turned a regular visit to the optometrist into an urgent surgical procedure, and the reassuring manner of the man who helped her navigate her way through.
“When Suren told me there’s something pressing on my optic nerve, he wasn’t an alarmist. He was just very straightforward, very calming, very assuring. He said, ‘You need to see your GP to get a referral for an MRI. And then they’ll take it from there’.”
She got a GP appointment the following morning and was booked for an MRI in nearby Corrimal that afternoon. Midway through her MRI, Pabis was advised she also required a CT scan.
“At that point, I knew they’d found something because that wasn’t ordered.”
Pabis was given a copy of the scans and followed up with her GP the next day.
“I read the scans. I saw what was there, but I didn’t know what it meant.”
Her GP confirmed Naidoo’s suspicions and contacted a neurosurgeon. She soon received the call from Wollongong Hospital, advising her to pack a bag.
Once admitted to hospital, Pabis was given hydrocortisone injections to reduce her blood pressure and blood sugar levels, in preparation for surgery.
“I was admitted on Wednesday night. They did their own MRIs and scans on Thursday, and I had to meet with the Ear, Nose and Throat team because they take the tumour out through the back of your nose. They removed a big chunk of my cartilage and took a chunk of fat from my thigh to make a plug in the back of my head,” she says.
Time lapse
“I’m a very energetic person but back in 2018, I had no energy. I’d sleep for 12 hours and wake up exhausted. I went to the GP and underwent a range of tests,” Pabis recalls.
Unbeknown to her, the tumour was already wreaking havoc.
“In 2020/2021 I started getting very severe tendinitis. I was exercising and doing low impact things like aqua aerobics that don’t put a lot of strain on your body. But I was always getting tennis elbow, and nothing would heal. Painkillers wouldn’t even take the pain away. So I was getting cortisone injections, which would help for three months, but then the pain would return.”
Now, nearly 12-months post-surgery, Pabis is pain free and her vision is stable.
“I’m lucky that I had Suren to explain what was happening. I’m assuming a lot of people wouldn’t take that extra step and explain this is what these symptoms mean,” she says.
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