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Visual disturbances and weight gain
  1. S Sharmaa,
  2. R Granota,
  3. N Thomasa,
  4. G A Wilcsekb,
  5. C Whitea,
  6. R Fitzsimonsb,
  7. J Tidmarshc,
  8. B E Tucha
  1. aPrince of Wales Hospital, Randwick, Sydney, Australia: Department of Endocrinology, bDepartment of Ophthalmology, cDepartment of Endocrinology, Bankstown Hospital, Bankstown, Sydney, Australia
  1. Professor B Tuch, Pancreas Transplant Unit, Department of Endocrinology, Diabetes and Metabolism, Prince of Wales Hospital, Corner Avoca and High Streets, Randwick, NSW 2031, Australiab.tuch{at}unsw.edu.au

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Answers on p 736.

A 51 year old man presented with a two year history of gradually deteriorating vision in his left eye, accompanied by 34 kg weight gain, easy bruising, and hypertension which was relatively resistant to conventional treatment. The patient denied any history of headaches. On examination, his general appearance was as shown (fig 1). On ocular examination his visual acuity was 6/6 in the right and 6/12 in the left eye. A left relative afferent pupillary defect was present and fundoscopically there was left optic nerve atrophy. Numerous investigations were performed, including Humphrey's field analysis (fig 2), and a cerebral magnetic resonance imaging (MRI) scan (fig 3). Eye positions on left lateral gaze were as shown (fig4).

Figure 1

Appearance of patient on presentation (reproduced with patient's permission).

Figure 2

Overview of Humphrey's visual field analyses over three years (FL = fixation losses, GHT = glaucoma hemifield test, MD = mean deviation, PSD = pattern standard deviation; SITA was the program used).

Figure 3

MRI scan: axial and coronal sections.

Figure 4

Eye position on left lateral gaze (reproduced with patient's permission).

Questions

(1)
Explain the ocular findings, and give the differential diagnosis.
(2)
What further investigations would you perform?
(3)
What does his MRI reveal?
(4)
Outline initial management, and, should this fail, what alternative treatment options exist?

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