Pituitary apoplexy presenting with isolated third nerve palsy

We report a 61-year-old gentleman who presented with sudden onset of worsening headache, diplopia and blurring of vision on the left eye. Examination showed presence of relative afferent papillary defect, with visual acuity of 1/60 in the affected eye. Additionally, there was third nerve palsy with pupil involvement. An urgent MRI of the brain imaging confirmed hemorrhagic pituitary tumor with upward compression onto optic chiasma and the upper part of cavernous sinus. Emergency transphenoidal decompression resulted in significant improvement of neurological signs and vision.