Chiasmal compression misdiagnosed as normal-tension glaucoma: can we avoid the pitfalls?

Routine neuroimaging for patients with presumed normal-tension glaucoma (NTG) is a contentious issue and it has been suggested that it may be unnecessary due to the low yield for detecting intracranial pathology. However, it has also been reported that 8% of patients diagnosed with NTG have associated compressive lesions of the anterior visual pathways. We present three patients in whom the initial diagnosis of NTG was eventually revealed to be chiasmal compression secondary to a pituitary tumour. Case 1: a 79-year-old woman was treated for NTG for several months before a bitemporal haemianopia developed and imaging showed a pituitary tumour. Case 2: an 83-year-old man was treated for NTG while a magnetic resonance imaging (MRI) scan was requested routinely. This subsequently revealed a pituitary tumour. Case 3: a 52-year-old man with left inferior arcuate visual field loss plus disc pallor was treated for NTG. His visual field deteriorated over 8 years, despite his intraocular pressure (IOP) being well controlled. An MRI was eventually requested, which revealed a pituitary tumour. All of our patients had signs that, with hindsight, should have raised suspicions about the presumptive diagnosis of NTG and initiated neuroimaging at an earlier stage. Whilst compression of the anterior visual pathways is an uncommon finding in patients thought to have NTG, features such as bitemporal field loss, optic disc pallor, poor colour vision and, particularly, poor disc/field correlation should alert the clinician to the possibility of an intracranial mass lesion.