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Sudden onset isolated complete third nerve palsy due to pituitary apoplexy

Oman Journal of Ophthalmology
Medknow Publications
Publication Date
DOI: 10.4103/0974-620x.77661
  • Clinical Images
  • Biology
  • Medicine


Pituitary apoplexy is characterized by a sudden onset of headache, visual impairment, opthalmoplegia, altered mental status, and hormonal dysfunction. It is a medical emergency caused by acute hemorrhage or infarction of the pituitary gland / tumor.[1] A rapid rise in intrasellar pressure causes compression of the adjacent cranial nerves resulting in cranial nerve palsy.[2] Isolated complete third nerve palsy due to pituitary apoplexy is uncommon.[3–5] We report a case of a sudden onset of isolated complete third nerve palsy as the presenting sign of pituitary apoplexy. A 55-year-old male presented with a sudden onset of a drooping right eyelid following an episode of mild-to-moderate headache. On admission, he was conscious and well-oriented to time, place, and person. His vision was 6 / 6 in both eyes and there was a mild bilateral temporal field restriction on confrontation examination. His right pupil was 5 mm in diameter and not reacting to light, while the left pupil was 3 mm and reacting to light. He had complete ptosis on the right side. The right eye was in a down and out position [Figure 1]. His left eye movements were normal. The remaining cranial nerve functions were normal. Magnetic resonance imaging (MRI) of the brain revealed a heterogeneously enhancing pituitary tumor, which was hyperintense on T-1 weighted images and hypointense on T2-weighted images [Figures 2 and 3]. Magnetic resonance angiography (MRA) was normal. Pituitary hormones were within normal levels. The sellar mass was excised via a sublabial transphenoidal approach. The tumor tissue along with altered blood was drained out. A near complete excision of the pituitary adenoma was achieved. The histopathological examination confirmed pituitary adenoma with extensive areas of hemorrhage and necrosis, consistent with apoplexy [Figure 4]. The postoperative course was uneventful and the patient had a good clinical recovery. At the six-week follow-up, the right-sided ptosis and eye movements had completely recovered; however, pu

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