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+A 68-year-old man was referred by his optometrist to HES with suspected LTG due to repeatedly irregular visual field test results, advanced optic disc cupping, normal intraocular pressures (IOPs) and a family history of glaucoma.
+The patient subjectively felt that vision in his ‘good’ left eye (LE), which normally had a visual acuity of 6/6 N5, started to deteriorate 6 months earlier; at the point of referral it was best corrected to 6/7.5 N6.
+His right eye (RE) was known to be amblyopic with a visual acuity of 6/18 N12.
+His medical history included considerable risk factors for systemic vasculopathy, such as hypertension, hypercholesterolaemia, 50 pack-years of smoking and type 2 diabetes with no diabetic retinopathy.
+Despite detailed questioning, he denied any new systemic symptoms apart from experiencing increased lethargy.
+Clinical examination at HES revealed advanced bilateral cupped optic discs with a cup-to-disc ratio right 0.9 (90%) and left 0.8 (80%; figure 1).
+Furthermore, the findings from the referring optometrist of equal and reactive pupils, normal eye movements and IOPs in mid-teens were confirmed.
+Computerised perimetry showed constricted visual fields in both eyes, albeit with considerably raised false-negative error rates in excess of 30% (figure 2A).
+Since this can be a result of poor concentration and attention span with testing compounded, especially with an amblyopic RE, the field test was repeated 4 weeks later with similar results (figure 2B).
+At this visit, the patient experienced further deterioration of his ‘good’ LE.
+Visual acuities measured 6/24 (loss of one Snellen line) N36 in his amblyopic RE, and 6/18 (loss of two Snellen lines) N36 in his LE, which now also showed depressed colour vision.
+An urgent scan of the patient's head and orbit was requested to rule out a compressive lesion and blood analysis was carried out to screen for other causes of optic neuropathy including vitamin B12, folate levels and inflammatory markers.
+MRI revealed a large mass centred at the pituitary fossa measuring approximately 4.5 cm×5.1 cm× 4.8 cm (figure 3A–C) extending into the suprasellar cistern and infrasellar sphenoid sinuses.
+The optic chiasm and both optic nerves were displaced superiorly and compressed on both sides.
+The mass showed heterogeneous T1 and T2 signals with multiple fluid levels most likely due to previous haemorrhage and low-signal components suggesting calcifications.
+The appearance was probably due to a craniopharyngioma or haemorrhagic pituitary adenoma.
+The patient was referred urgently to the neurosurgery unit and was found to have markedly raised prolactin levels of greater than 200 000 mIU/L, confirming the diagnosis of a giant prolactinoma.
+In cooperation with the local endocrinology service, he was started on cabergoline 500 µg and dexamethasone 8 mg.
+Within a week this led to a dramatic improvement of the patient's visual fields and acuities to 6/18 RE and to 6/9 LE.
+His prolactin levels showed a similar dramatic response with levels coming down to 336 mIU/L.
+Three months later his visual acuity in his RE and LE were 6/18 and 6/5, respectively, and visual field examination showed striking recovery with almost normal results (figure 2C).