J Korean Ophthalmol Soc.  2019 Oct;60(10):1010-1014. 10.3341/jkos.2019.60.10.1010.

Pituitary Apoplexy Presenting as Isolated Bilateral Oculomotor Nerve Palsy

• Cho H
• Song YJ
• Ryu WY

• KMID: 2460522
• DOI: http://doi.org/10.3341/jkos.2019.60.10.1010

Abstract

PURPOSE
To report a case of pituitary apoplexy presenting as isolated bilateral oculomotor nerve palsy.
CASE SUMMARY
A 46-year-old male presented with bilateral ptosis and acute severe headaches for 6 days. He underwent head surgery and bilateral vitrectomy 12 years prior to his visit because of ocular and head trauma. He mentioned that previous visual acuities in both eyes were not good. The initial corrected visual acuity was finger counting in the right eye and 20/500 in the left eye. Ocular motility testing revealed the limitation of adduction, supraduction, and infraduction with complete bilateral ptosis in both eyes, and his left pupil was dilated. He was diagnosed with an isolated bilateral oculomotor nerve palsy. Magnetic resonance imaging indicated pituitary gland hemorrhage with a tumor, which was suspicious of pituitary apoplexy. The patient was treated intravenous with 1.0 g methylprednisolone to prevent the corticotropic deficiency. In addition, he underwent surgical decompression using a navigation-guided transsphenoidal approach and aspiration biopsy. He was confirmed with pituitary adenoma using a pathological examination. The patient's ocular movements began to dramatically improve by the third day postoperatively. At 4 months postoperative follow-up, his ocular movement and double vision were completely recovered.
CONCLUSIONS
This was a rare case of pituitary apoplexy with bilateral isolated oculomotor nerve palsy, which was the first report in the Republic of Korea. A full recovery was achieved after early surgical treatment.

Keyword

Cranial nerve palsy; Oculomotor nerve disease; Oculomotor nerve palsy; Pituitary adenoma; Pituitary apoplexy

MeSH Terms

Biopsy, Needle
Cranial Nerve Diseases
Craniocerebral Trauma
Decompression, Surgical
Diplopia
Fingers
Follow-Up Studies
Head
Headache
Hemorrhage
Humans
Magnetic Resonance Imaging
Male
Methylprednisolone
Middle Aged
Oculomotor Nerve Diseases*
Oculomotor Nerve*
Pituitary Apoplexy*
Pituitary Gland
Pituitary Neoplasms
Pupil
Republic of Korea
Visual Acuity
Vitrectomy
Methylprednisolone

Figure

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  Figure 1 Nine cardinal gaze position at initial visit. Ocular movement was revealed the limitation of adduction, supraduction, and infraduction with complete ptosis in both eyes and a dilated pupil was shown in the left eye.

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  Figure 2 Magnetic resonance images. Pituitary apoplexy was shown with large cystic lesion on T1 weighted images (arrows) (A, sagittal view, B, axial view).

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  Figure 3 Nine gaze photos at postoperative 4 months. Ocular eye movement and dilated pupil in the left eye were completely recovered.

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