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Background Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of PA patients. Methods A retrospective chart review of all patients with PA seen in our Pituitary Center (1/1995–12/2012) was conducted. Presenting neuro-ophthalmic, endocrine, and radiologic data as well as neuro-ophthalmology follow-up were collected. Results We identified 235 PA patients, among whom 59 (25%) had OMD; 27/59 had neuro-ophthalmic evaluation. Pre-operatively, 23/27 patients had unilateral OMD, 18/23 (78%) had single and 5/23 (22%) multiple CNPs. Bilateral OMD was present in 4/27 patients. Postoperatively, 24/27 OMD patients had follow-up (median duration: 7 months [IQR: 3–17]). At last post-operative follow-up, 7/24 (29%) patients had OMD (5 unilateral, 2 bilateral). OMD resolved in 3/24 (12%) patients within 1 month, 13/21(62%) patients within 6 months (3 lost to follow-up), and 17/19 (89%) within one year (2 lost to follow-up). Surgery occurred ≤14 days post-presentation in 16/18 (89%) of resolved vs. 4/6 (67%) of unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm, p<0.001), panhypopituitarism (31% vs. 14%, p=0.005), and necrosis (58% vs. 37%, p=0.03). Conclusion Ocular motility dysfunction from cranial nerve palsies is common in PA, occurring in one-quarter of patients, and are more frequently associated with certain radiologic, endocrinologic, and pathologic features. The prognosis is excellent, with 90% of OMD resolved at one year after early pituitary surgery.

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