Unilateral oval pupil has numerous causes, and several pathophysiologic mechanisms have been proposed. Prognosis is nearly universally poor. We present two patients, an 86-year-old woman and a 61-year-old woman, who developed coma and unilateral oval pupil due to ischemia and hypoglycemia, respectively. In the second case, a discrete area of ipsilateral brainstem ischemia was demonstrated by magnetic resonance imaging. Both patients recovered. The prognosis for comatose patients with unilateral oval pupil is not universally poor.