Third nerve palsies without pupil involvment can still be surgical

Purpose To emphasise the importance of maintaining a high index of suspicion of a surgical cause of a partial third nerve palsy even when pupil is not involved. To highlight an unusual presentation of a pituitary tumour. Methods Case Report Results A 15 year old presented to the emergency department one evening after noticing he had a "droopy eyelid". He reported being under a lot of stress whilst revising for exams and described some occasional mild tension type headaches. Of note two weeks before this presentation he had "fainted" in the school playground, it had felt that this episode required no further investigation at the time. There was no other history ellicited. Also of note was that he denied any diplopia or visual symptoms. On presentation, he had a right sided partial ptosis. Visual acuity was normal. Both eyes were normal. On examintion of the ocular movements he had diplopia on upgaze especially in abduction. He had no past ocular or medical history. Goldmann fields were normal. When he was seen it was noted thet he was over 6 feet tall yet his parents were of average height. On discussing the case with radiologists and paediatricains great emphasis was placed by them on the lack of pupil involvement, it was then assumed therefore that it would be unlikely that there would be any brain lesion. However, he did go on to have an MRI scan the next day which revealed a large pituitary mass which protruded laterally hence the third nerve involvment. As of when this abstract was submitted he is awaiting neurosurgical work up. Conclusion Importance of high index of suspicion of surgical cause of third nerve palsyy depsite pupil involvement. To Highlight an unusual presentation of pituitary tumour