The incidence of visual impairment in pituitary apoplexy is variable. In a large series of pituitary apoplexy reported by Semple and colleagues, impairment of visual acuity was found in 56 % of patients, visual field defects were found in 34 % of patients and 10 % of patients presented with bilateral blindness (Semple et al. 2005).

Woo and colleagues studied the visual outcome in patients with pituitary apoplexy (Woo et al. 2010). In their study of 359 patients with pituitary tumours, pituitary apoplexy occurred in 3.3 % (Woo et al. 2010). Visual acuity improved in 91.6 % of patients and visual field defects improved in 54.5 % of patients at 3 months following transsphenoidal surgery. Complete recovery or partial recovery of visual acuity was seen in all patients who underwent surgery within the first 3 days of presentation as compared to 83.3 % of patients who underwent surgery beyond 3 days (Woo et al. 2010). Similarly, complete or partial recovery of visual field defects was seen in 66.6 % in patients who underwent surgery within 3 days as compared to 40 % of patients who underwent surgery after 3 days (Woo et al. 2010). Two of their patients had complete blindness following pituitary apoplexy and both patients underwent surgery 18 and 24 h following the apoplectic event and both showed improvement in vision 3 months following surgery. Dubuisson and colleagues (2007) studied 24 patients with pituitary apoplexy among their series of 1,540 pituitary lesions and found that visual field deficits were present in 50 % of patients at the time of presentation and all except two patients noted improvement in vision. Semple and colleagues (2005) reported improvement in visual acuity in 76 % and visual field defects in 79 % of patients. However, they did not analyse the influence of timing of surgery on the outcome. Bill and colleagues (1993) studied 37 patients with pituitary apoplexy and noted that there was improvement in visual acuity in 88 % and visual field defects in 95 % of patients, and improvement in visual acuity was significantly better in those who underwent surgery within the first week of onset of symptoms with all patients improving when operated within the first week. When subgroup analysis was made for patients operated within the first 3 days and those operated between 4 and 7 days, there was no difference (Bill et al. 1993). Three of their patients had unilateral blindness before surgery, and in two of them operated within the first week, there was complete recovery, and in the third patient who was operated 2 weeks after the onset, the visual acuity improved to 20/80 (Bill et al. 1993). Randeva and colleagues (1999) reported 35 patients with classical pituitary apoplexy and noted that complete resolution of impaired visual acuity occurred in all patients operated within 8 days of onset but only in 46 % of patients operated after 8 days, and complete restoration of visual field deficits occurred in 75 % of patients operated within 8 days versus 23 % of patients operated after 8 days. Takeda et al. studied the visual outcome in 12 patients with pituitary apoplexy and noted recovery of visual acuity in all patients with complete or near-complete visual recovery in 75 % of patients (Takeda et al. 2010). Based on their experience, they recommended that decompressive surgery is preferable within 7 days of symptom onset (Takeda et al. 2010). Muthukumar and colleagues (2008) studied the influence of the timing of surgery on the neuro-ophthalmic outcome in patients with unilateral or bilateral blindness due to pituitary apoplexy and found that patients who were operated within the first week showed good visual improvement even when they had bilateral blindness where as the visual outcome was suboptimal when the surgery was delayed beyond 1 week. Agrawal and Mahapatra (2005) reported 8 patients with unilateral or bilateral blindness following pituitary apoplexy and noted that 50 % of patients improved when surgery was done within 7 days of the apoplexy. Sibal and colleagues (2004) reported 45 patients with pituitary apoplexy among whom 60 % were operated; the median time to surgical intervention in their series was 6 days. In their series, complete or near-complete resolution of visual acuity and visual field defects occurred in 93 and 94 % of cases, respectively. Seuk and colleagues (2011) reported 32 patients with pituitary apoplexy and they compared the outcome of patients who were operated within 48 h with those who were operated after 48 h. In their series, they noted improvement of visual acuity and visual fields in 83.3 and 88.2 %, respectively, of patients operated within the first 48 h when compared to 62% and 50 % in patients who were operated after 48 h, thus emphasizing the importance of early surgical intervention in the visual outcome (Seuk et al. 2011). Chuang and colleagues (2006) studied 13 patients with severe visual compromise after pituitary apoplexy and divided them into two groups: those who underwent surgery within 3.5 days and those who underwent surgery after a mean delay of 8.7 days because of associated medical illnesses; they found that 100 % of patients operated within 3.5 days showed visual improvement, whereas only 50 % of patients operated after a delay of 8.5 days showed visual improvement.

Woo and colleagues (2010) studied the outcome of cranial neuropathy in their 12 patients with pituitary apoplexy among their 359 patients with pituitary apoplexy. They noticed either a complete or partial recovery of extraocular palsies in all their patients with pituitary apoplexy. This improvement was not associated with the timing of surgery, i.e. irrespective of the timing of surgery recovery of extraocular palsy was the rule (Woo et al. 2010). They also noted that recovery of sixth cranial nerve palsy always occurred earlier than third cranial nerve palsy (Woo et al. 2010). The earliest beginning of recovery was within 4 days and the latest was 56 days. The recovery of extraocular palsies reached a plateau at 3 months following intervention (Woo et al. 2010). Dubuisson and colleagues (2007) found an incidence of 54 % of extraocular palsies in their series of 24 patients with pituitary apoplexy and 85 % of them improved during follow-up. In the series by Bill and colleagues (1993), all patients with extraocular palsies improved and the improvement was irrespective of the timing of surgery. In Randeva and colleagues’ (1999) series of 35 patients with classical pituitary apoplexy, there was no statistically significant difference in the outcome of extraocular palsies in patients operated within the first 8 days and thereafter. Randeva et al. (1999) noted that ophthalmoplegia tends to recover, albeit partially, even when the surgical decompression is delayed due to factors such as the existence of medical co-morbidities. Among the 12 patients with pituitary apoplexy reported by Takeda et al. (2010), all the patients with extraocular palsy improved, but no mention was made regarding the timing of surgery and outcome. Muthukumar and colleagues (2008) studied the neuro-ophthalmic outcome in patients with pituitary apoplexy and found that the timing of surgery had no influence on the outcome of extraocular palsy, i.e. even patients who were operated after 1 week showed improvement in their extraocular palsy. In Sibal et al.’s (2004) series of 45 patients with pituitary apoplexy, 93 % of surgically treated patients recovered from the extraocular palsy. In the series reported by Semple and colleagues (2005), there was an incidence of 45 % of extraocular palsy, and among these, 91 % of patients showed improvement. However, there was no mention about the influence of timing of surgery on the outcome of extraocular palsy.