As per UK guidelines (Rajasekaran et al. 2011), initial assessment of the patients presenting with symptoms consistent with pituitary apoplexy should include a detailed history focusing on symptoms of pituitary dysfunction, e.g. symptoms of hypogonadism, followed by a thorough physical examination including cranial nerves and visual fields to confrontation. A formal visual field assessment using Humphrey visual field analyzer or Goldmann perimeter must be undertaken when the patient is clinically stable, preferably within 24 h of the suspected diagnosis, and in patients with reduced visual acuity or defective visual fields, formal assessment of visual fields and acuity should be performed every day until a clear trend of improvement is observed. Importantly, the guidelines also state that the presence of a new or deteriorating visual deficit or neurological deterioration should prompt further imaging with a view to decompressive surgery (including external ventricular drain placement in the presence of hydrocephalus).

There are few studies assessing visual outcome after pituitary apoplexy. Of these, only five studies (Table 11.1) have specifically addressed the pattern of visual recovery following surgical decompression (da Motta et al. 1999; Randeva et al. 1999; Agrawal and Mahapatra 2005; Chuang et al. 2006; Zhang et al. 2007; Seuk et al. 2011). Surprisingly, there are only four studies documenting return of vision after surgical or conservative management in patients who became blind subsequent to pituitary apoplexy (Krueger et al. 1960; Robinson 1972; Maccagnan et al. 1995; Agrawal and Mahapatra 2005).

Visual field deficits improve to a greater extent than visual acuity with studies reporting improvement in 89–95 % of the patients operated (Cardoso and Peterson 1984; da Motta et al. 1999; Zhang et al. 2007).

Overall, surgery results in improvement of the visual acuity deficits in 82–88 % of patients (Cardoso and Peterson 1984; da Motta et al. 1999). Return of vision was noted within 24 h of surgery in all cases who had a good visual outcome, and the improvement continued for variable period (Agrawal and Mahapatra 2005).

Suri et al. (2008) analysed a mixed group of 79 suprasellar tumours who presented with blindness and noted improvement in serviceable vision in 8.9 of eyes with preoperative blindness. However, the study group was very heterogenous with pre-existing blindness for variable periods as long as 7 years. Other studies have shown that surgery within a week of the apoplexy results in improved visual outcome. In our own study of 23 patients who underwent transsphenoidal surgery for pituitary apoplexy over a 5-year period, 8 (35 %) presented with visual deterioration to monocular (n = 2) or binocular (n = 6) blindness after the apoplectic episode. Postoperatively, four patients (50 %) had improvement in vision to greater than 2/60 (Snellen’s), including two patients whose vision improved to 6/6. All patients in whom there was improvement in vision had been operated on within a week of the apoplectic episode (Agrawal and Mahapatra 2005). Muthukumar et al. (2005) analysed four patients who presented with blindness within 1 week after pituitary apoplexy and found that the patient who was operated on within the first week recovered from bilateral blindness to a visual acuity of 6/9 and 6/12 with superior quadrantic field defects. The two patients who were operated on 2 and 3 weeks after ictus improved to 6/60 in the affected eyes and the patient who was operated on after 2 months improved to 1/60 in the affected eye. The authors concluded that “early” surgery within the first week after ictus leads to excellent visual outcome when compared with surgery that is performed at a later stage.