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A 64-year-old woman with dilated right pupil, nausea, and headache
Digital Journal of Ophthalmology 2013
Volume 19, Number 1
January 27, 2013
DOI: 10.5693/djo.03.2012.11.001
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Ali Haider, BMedSc, MBBS | The Canberra Hospital, Canberra, Australia
Prashanth J. Rao, MBBS, MS | The Canberra Hospital, Canberra, Australia
Differential Diagnosis
An ischemic etiology is considered in patients presenting with a pupil-sparing, oculomotor nerve palsy. Such patients should have a complete blood count, including glucose and cholesterol studies.

This patient presented with pupil-involving oculomotor nerve palsy. An important differential that must be considered with pupil involvement is an evolving compressive oculomotor nerve lesion. An urgent angiogram is needed to exclude an aneurysm.

Acute-onset paralysis of the oculomotor nerve has been described as the chief presenting complaint of pituitary apoplexy in only a few cases in the literature.(1) Pituitary apoplexy refers to the clinical syndrome associated with hemorrhagic infarction of a preexisting pituitary adenoma, classically manifesting with the sudden onset of headache, nausea and vomiting, visual impairment (decreased acuity, field deficits, or impaired ocular motility), and altered mental status. The word “apoplexy” is of Greek origin and describes the accumulation of blood or fluid within any organ.(1) Apoplectic events are unpredictable and often misdiagnosed.(2) The presentation may also be complicated by meningism. Delayed diagnosis increases the risk of permanent visual impairment. Successful management of pituitary apoplexy relies on early diagnosis, with appropriate medical management of acute adrenal insufficiency and surgical intervention to optimize visual outcome. The history may have clues to the longstanding presence of a pituitary tumor (headache, visual loss, endocrine problems), with the acute episode manifested by signs of compression by hematoma and pituitary destruction. Pituitary function tests, such as prolactin, thyroid function, and gonadotropins, are also essential to guide further hormonal therapy and confirm the extent of pituitary compromise.
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