A 15-year-old previously healthy boy had a chief symptom of double vision. The patient had visited a neurologist 2 months before for headaches, vision changes, and vomiting. Magnetic resonance imaging of the brain revealed a pineal region tumor with hydrocephalus. He underwent an endoscopic third ventriculostomy and biopsy of the tumor in an outside hospital. The tumor biopsy and markers that were taken were inconclusive. Two weeks later, he underwent a right occipital craniotomy with transtentorial microscopic subtotal resection of the tumor. Pathological findings were consistent with germinoma. Three days after surgery, he was seen in the ophthalmology clinic with diplopia. On examination, uncorrected visual acuity was 20/30 OD and 20/60 OS. Ductions and versions showed −4 limitation of elevation in all of the horizontal gaze positions, −½ abduction deficits in both eyes, and a −2 depression deficit in both eyes. In primary position, he had 10 PD of esotropia, which increased to 15 PD in both left and right gaze. The clinical impression was consistent with resolving increased intracranial pressure and herniation syndrome resulting in bilateral sixth cranial nerve palsies. The patient then was treated with radiation therapy to the pineal region with a maximum dose of 5040 cGy to the primary tumor site and an estimated total dose of 2520 cGy to the hypothalamus and pituitary.