Nystagmus — MCQs
A person presenting to the outpatient department with complaints of rotational vertigo and nausea in the morning, which worsens with changes in head position. What is your diagnosis?
Which of the following is true about multiple sclerosis except
Difference between central and peripheral vertigo:
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
Which of the following investigations is not necessary for evaluating optic neuritis?
What is true about optic nerve glioma?
Waves present in electroretinogram are all EXCEPT:
A patient presents with right eye superotemporal quadrantopia and left eye centrocaecal scotoma, accompanied by headache. What is the most likely site of the lesion?
All of the following are features of a tonic pupil, EXCEPT?
A patient presents with limitation of abduction of the right eye and horizontal diplopia. Which cranial nerve is most likely affected?
Nystagmus Indian Medical PG Practice Questions and MCQs
Question 1: A person presenting to the outpatient department with complaints of rotational vertigo and nausea in the morning, which worsens with changes in head position. What is your diagnosis?
- A. Labyrinthitis
- B. BPPV (Correct Answer)
- C. Vestibular neuronitis
- D. Meniere's disease
Explanation: ***BPPV (Benign Paroxysmal Positional Vertigo)*** - **Rotational vertigo** that is triggered by specific **head position changes** and often noticed upon waking or turning in bed is highly characteristic of BPPV. - The symptoms are typically brief, intense, and associated with **nausea**, resolving within seconds to minutes. *Labyrinthitis* - Labyrinthitis presents with **continuous vertigo** and often includes **hearing loss** and **tinnitus**, which are not mentioned in the patient's symptoms. - The vertigo in labyrinthitis is usually constant, not positional, and is caused by inflammation of the inner ear. *Vestibular neuronitis* - Vestibular neuronitis is characterized by **sudden, severe, and persistent vertigo** without hearing loss, often following a viral infection. - Unlike BPPV, the vertigo does not primarily worsen with specific head position changes but is more constant. *Meniere's disease* - Meniere's disease involves a classic triad of **recurrent episodes of vertigo**, **tinnitus**, and **fluctuating sensorineural hearing loss**, often accompanied by aural fullness. - The vertigo attacks are typically severe and last for hours, which is longer than the brief episodes seen in BPPV.
Question 2: Which of the following is true about multiple sclerosis except
- A. Nystagmus on adducting eye
- B. One and half syndrome
- C. Pendular nystagmus (Correct Answer)
- D. Nystagmus on abducting eye
Explanation: ***Pendular nystagmus*** - **Pendular nystagmus** is a rhythmic oscillation of the eyes that is not typically described as a classic finding in **multiple sclerosis (MS)**. While nystagmus (involuntary eye movements) is common in MS due to demyelination in the brainstem or cerebellum, the specific pattern usually observed is **jerk nystagmus**. - **Pendular nystagmus** is characterized by equal velocity in both directions of movement, lacking a fast and slow phase, and is more commonly associated with conditions like congenital nystagmus or severe visual impairment. *Nystagmus on adducting eye* - **Nystagmus on adducting eye** is a component of **internuclear ophthalmoplegia (INO)**, which is a classic brainstem syndrome caused by demyelination in the **medial longitudinal fasciculus (MLF)** in MS [1]. - In INO, the adducting eye exhibits nystagmus, while the abducting eye shows normal movement or mild nystagmus. *One and half syndrome* - **One and a half syndrome** is a severe form of INO, indicating a more extensive lesion in the **paramedian pontine reticular formation (PPRF)** and the adjacent **medial longitudinal fasciculus (MLF)**. - This syndrome results in the inability to move one eye horizontally past the midline (half a gaze paralysis) and the other eye only in abduction (one gaze paralysis), with nystagmus in the abducting eye. It is a highly characteristic finding in MS. *Nystagmus on abducting eye* - The **abducting eye** in **internuclear ophthalmoplegia (INO)**, a common manifestation of MS, often exhibits **nystagmus**. - This is due to the compensatory increase in neural impulse to the abducting eye to overcome the weak adduction of the contralateral eye, further indicating a lesion in the **medial longitudinal fasciculus (MLF)**.
Question 3: Difference between central and peripheral vertigo:
- A. Tinnitus and deafness are often present in peripheral vertigo (Correct Answer)
- B. Multidirectional nystagmus that changes with gaze direction is common in central vertigo
- C. Nystagmus associated with central vertigo is unidirectional
- D. Central is more severe than peripheral vertigo
Explanation: ***Tinnitus and deafness are often present in peripheral vertigo*** - **Peripheral vertigo** arises from problems in the **inner ear** or **vestibulocochlear nerve**, which are also responsible for hearing, thus often presenting with associated **tinnitus** or **hearing loss** [1]. - Conditions like **Meniere's disease** and **labyrinthitis** are classic examples where auditory symptoms accompany the sensation of dizziness [1]. *Multidirectional nystagmus that changes with gaze direction is common in central vertigo* - This statement is **incorrect** as **multidirectional nystagmus** (e.g., vertical, purely torsional, or changing direction with gaze) that does not suppress with fixation is a characteristic feature of **central vertigo** [2]. - **Nystagmus** in central vertigo is often **purely vertical** or **torsional**, can change direction with gaze, and does **not typically fatigue** or habituate. *Nystagmus associated with central vertigo is unidirectional* - This statement is **incorrect** because **unidirectional nystagmus** (fast phase always beating in one constant direction regardless of gaze) is more characteristic of **peripheral vertigo**. - In **central vertigo**, nystagmus can be **multidirectional**, **purely vertical**, or **torsional**, and its direction may **change with the direction of gaze**. *Central is more severe than peripheral vertigo* - This statement is **incorrect** because the **severity of vertigo perception** is often **more intense** in **peripheral vertigo** due to the sudden and often disabling vestibular imbalance. - While **central vertigo** can be associated with more **severe underlying neurological conditions**, the *sensation* of spinning itself is typically perceived as less severe and more often accompanied by other neurological deficits, rather than solely intense spinning.
Question 4: In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
- A. Head turned to right, corrective saccade to the left (Correct Answer)
- B. Head turned to left, corrective saccade to the right
- C. Head turned to right, no corrective saccade
- D. Head turned to left, no corrective saccade
Explanation: ***Head turned to right, corrective saccade to the left*** - In **right vestibular neuronitis**, the right vestibular apparatus is impaired, affecting the **vestibulo-ocular reflex (VOR)** on that side. - During the head impulse test, when the head is rapidly turned **to the right** (toward the affected side), the impaired VOR cannot maintain eye fixation on the target. - The eyes initially move **with the head** (to the right), then a visible **corrective saccade** (catch-up saccade) brings them **back to the left** to refixate on the target. - This corrective saccade is the **hallmark positive finding** in head impulse test for right vestibular dysfunction. *Head turned to left, corrective saccade to the right* - This would indicate a **left vestibular lesion**, not right vestibular neuronitis. - When turning the head to the left with left vestibular dysfunction, a corrective saccade to the right would be observed. *Head turned to right, no corrective saccade* - This would indicate **normal VOR function** on the right side. - A normal response shows no corrective saccade because the eyes maintain fixation throughout the head turn. - This is the **opposite** of what is expected in right vestibular neuronitis. *Head turned to left, no corrective saccade* - This indicates normal VOR function on the left side. - In right vestibular neuronitis, turning the head to the left (away from the affected side) typically shows **normal VOR** with no corrective saccade needed.
Question 5: Which of the following investigations is not necessary for evaluating optic neuritis?
- A. MRI of the head and orbit
- B. Erythrocyte Sedimentation Rate (ESR)
- C. Ultrasonography B-scan (Correct Answer)
- D. Visual fields assessment
Explanation: **Explanation:** Optic neuritis is an inflammatory condition of the optic nerve, most commonly associated with Multiple Sclerosis (MS). The diagnosis is primarily clinical, but investigations are focused on confirming the diagnosis, assessing the extent of damage, and determining the risk of systemic demyelination. **Why B-scan is the correct answer:** **Ultrasonography B-scan** is used to visualize the posterior segment of the eye when the media (cornea, lens, or vitreous) is opaque. It is useful for detecting retinal detachment, vitreous hemorrhage, or intraocular tumors. It has no diagnostic value in optic neuritis because the pathology is retrobulbar or involves the nerve fibers, which are better visualized via neuroimaging. **Why the other options are necessary:** * **MRI of the head and orbit (with Gadolinium):** This is the most important investigation. It confirms optic nerve inflammation (showing enhancement) and identifies white matter plaques in the brain, which are crucial for predicting the risk of developing Multiple Sclerosis. * **Erythrocyte Sedimentation Rate (ESR):** While optic neuritis is usually idiopathic or demyelinating, ESR is checked to rule out inflammatory or systemic autoimmune mimics, such as Neuromyelitis Optica (NMO) or giant cell arteritis in older patients. * **Visual fields assessment:** Automated perimetry (e.g., Humphrey Visual Field) is essential to document the type of defect. The most common finding is a **central or centrocecal scotoma**. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Sudden unilateral vision loss, periocular pain (worsened by eye movement), and dyschromatopsia (impaired red-green color vision). * **Marcus Gunn Pupil:** A Relative Afferent Pupillary Defect (RAPD) is a hallmark sign. * **Pulfrich Phenomenon:** Objects moving in a straight line appear to move in curved paths due to delayed conduction in the affected nerve. * **Uhthoff’s Phenomenon:** Temporary worsening of symptoms with increased body temperature (e.g., after a hot bath or exercise).
Question 6: What is true about optic nerve glioma?
- A. Seen in old individuals
- B. Painful proptosis
- C. Can cause hematoma
- D. Unilateral proptosis (Correct Answer)
Explanation: **Optic Nerve Glioma** is a slow-growing, benign tumor (typically a juvenile pilocytic astrocytoma) that arises from the glial cells of the optic nerve. ### **Explanation of Options** * **D. Unilateral proptosis (Correct):** This is the hallmark clinical presentation. As the tumor grows within the optic canal or orbit, it pushes the globe forward. The proptosis is typically **axial** (straight forward) and **non-pulsatile**. * **A. Seen in old individuals:** Incorrect. This is primarily a disease of **childhood**, with 90% of cases diagnosed in the first two decades of life (peak age 2–6 years). In adults, optic nerve tumors are more likely to be malignant glioblastomas or meningiomas. * **B. Painful proptosis:** Incorrect. Optic nerve glioma causes **painless**, slowly progressive proptosis. Painful proptosis is more characteristic of inflammatory conditions (like orbital pseudotumor) or infections (orbital cellulitis). * **C. Can cause hematoma:** Incorrect. While some vascular tumors (like lymphangiomas) can cause sudden hemorrhage (chocolate cysts), gliomas do not typically present with hematoma. ### **High-Yield Clinical Pearls for NEET-PG** * **Association:** Strongly associated with **Neurofibromatosis Type 1 (NF-1)**. If bilateral optic nerve gliomas are present, NF-1 is almost certain. * **Imaging:** MRI shows a characteristic **fusiform (spindle-shaped) enlargement** of the optic nerve. A "kinking" or "buckling" of the nerve may also be seen. * **Visual Symptoms:** Gradual, painless loss of vision is common. On examination, look for an **Afferent Pupillary Defect (RAPD)** and optic atrophy or disc edema. * **Management:** Often follows a benign course; "observation" is preferred if vision is stable. Surgery or radiotherapy is reserved for progressive cases or intracranial extension.
Question 7: Waves present in electroretinogram are all EXCEPT:
- A. a wave
- B. b wave
- C. c wave
- D. d wave (Correct Answer)
Explanation: **Explanation:** The **Electroretinogram (ERG)** is a diagnostic test that measures the electrical response of various cell layers in the retina to a light stimulus. A standard ERG waveform consists of three primary components: **a, b, and c waves.** * **Correct Answer (D):** The **d-wave** is not considered a standard component of the clinical ERG waveform. While some specialized research contexts refer to a "d-wave" as an "off-response" (occurring when the light stimulus is turned off), it is not part of the classic clinical ERG used to assess retinal function in standard examinations. **Analysis of Other Options:** * **A. a-wave:** This is the first **negative** deflection. It represents the activity of the **photoreceptors** (rods and cones) in the outer retinal layer. * **B. b-wave:** This is the large **positive** deflection following the a-wave. It is the most clinically significant wave and represents the health of the **inner retinal layers**, specifically the **Müller cells and Bipolar cells.** * **C. c-wave:** This is a prolonged, lower-amplitude positive wave following the b-wave. It originates from the **Retinal Pigment Epithelium (RPE)** in response to changes in subretinal potassium concentration. **High-Yield Clinical Pearls for NEET-PG:** * **Origin Summary:** a-wave (Photoreceptors), b-wave (Bipolar/Müller cells), c-wave (RPE). * **Oscillatory Potentials:** These are small ripples found on the ascending limb of the b-wave, originating from **Amacrine cells**. They are characteristically lost early in **Diabetic Retinopathy**. * **Negative ERG:** A condition where the a-wave is preserved but the b-wave is significantly reduced or absent. This is classically seen in **Central Retinal Artery Occlusion (CRAO)** and **Congenital Stationary Night Blindness (CSNB)**. * **EOG (Electro-oculogram):** Measures RPE function; the key parameter is the **Arden Index** (Normal > 1.8).
Question 8: A patient presents with right eye superotemporal quadrantopia and left eye centrocaecal scotoma, accompanied by headache. What is the most likely site of the lesion?
- A. Left optic nerve and chiasm (Correct Answer)
- B. Left optic tract and chiasm
- C. Right optic nerve and chiasm
- D. Right optic tract and chiasm
Explanation: ### Explanation This clinical presentation describes a **Junctional Scotoma**, a classic neuro-ophthalmological finding localized to the junction of the optic nerve and the optic chiasm. **1. Why Option A is Correct:** The lesion is located at the **posterior aspect of the left optic nerve** where it joins the chiasm. * **Left Centrocaecal Scotoma:** Caused by direct compression of the left optic nerve fibers (specifically the papillomacular bundle). * **Right Superotemporal Quadrantopia:** This occurs because the **inferonasal fibers** from the contralateral (right) eye loop into the terminal part of the ipsilateral (left) optic nerve before crossing the chiasm. This anatomical loop is known as **Wilbrand’s Knee**. Damage to these fibers results in a superior temporal defect in the opposite eye. **2. Why Incorrect Options are Wrong:** * **Option B (Left Optic Tract):** A lesion here would cause a Right Homonymous Hemianopia, not a localized scotoma and quadrantopia. * **Option C (Right Optic Nerve):** A right-sided lesion would cause a right-sided centrocaecal scotoma and a left-sided superotemporal defect (the reverse of the presentation). * **Option D (Right Optic Tract):** This would result in a Left Homonymous Hemianopia. **3. NEET-PG High-Yield Pearls:** * **Wilbrand’s Knee:** The key anatomical structure responsible for the "junctional" nature of the visual field defect. * **Common Cause:** Often caused by a **Meningioma** (tuberculum sellae) or a **Pituitary Adenoma** extending superiorly. * **Visual Field Rule:** Always remember that "nasal fibers cross." Inferonasal fibers (responsible for the superotemporal field) loop anteriorly into the opposite optic nerve. * **Junctional Scotoma of Traquair:** A variation where there is a central scotoma in one eye with a temporal hemianopic defect in the same eye (rarely tested but good to distinguish).
Question 9: All of the following are features of a tonic pupil, EXCEPT?
- A. It is caused by damage to the oculomotor nerve (Correct Answer)
- B. Accommodative paresis is present
- C. Cholinergic supersensitivity of the denervated muscle is present
- D. Reaction to light is absent and the reaction to near reflex is very slow and tonic
Explanation: **Explanation:** The correct answer is **A (It is caused by damage to the oculomotor nerve)**. A tonic pupil (Adie’s Pupil) is caused by damage to the **ciliary ganglion** or the **short ciliary nerves**, not the main trunk of the oculomotor nerve (CN III). While CN III carries preganglionic parasympathetic fibers, the pathology in a tonic pupil is postganglionic. **Analysis of Options:** * **Option A (Incorrect Statement):** Damage to the oculomotor nerve typically results in a complete "blown pupil" with associated ptosis and motility deficits. In contrast, Adie’s pupil is an isolated pupillary abnormality due to postganglionic denervation. * **Option B (Correct Feature):** Damage to the ciliary ganglion affects the nerve supply to the ciliary muscle, leading to **accommodative paresis** (blurred near vision). * **Option C (Correct Feature):** Following denervation, the sphincter pupillae becomes hypersensitive to acetylcholine. This is the basis of the diagnostic test using **dilute Pilocarpine (0.125%)**, which constricts an Adie’s pupil but has no effect on a normal pupil. * **Option D (Correct Feature):** This describes **Light-Near Dissociation**. The pupil reacts poorly to light because of damaged fibers, but reacts slowly and "tonically" to near effort due to aberrant regeneration of fibers originally intended for the ciliary muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in young women; often unilateral (80%) but can become bilateral. * **Holmes-Adie Syndrome:** Adie’s pupil associated with **diminished deep tendon reflexes** (usually ankle jerks). * **Mnemonic:** "Adie’s is **A**dded (dilated) and **A**nkle jerks are down." * **Light-Near Dissociation (LND):** Other causes include Argyll Robertson Pupil (Neurosyphilis) and Parinaud Syndrome (Dorsal Midbrain Syndrome).
Question 10: A patient presents with limitation of abduction of the right eye and horizontal diplopia. Which cranial nerve is most likely affected?
- A. Optic nerve
- B. Oculomotor nerve
- C. Trochlear nerve
- D. Abducens nerve (Correct Answer)
Explanation: **Explanation:** The clinical presentation of **limited abduction** and **horizontal diplopia** is the classic hallmark of a **6th Cranial Nerve (Abducens nerve) palsy**. **1. Why the Correct Answer is Right:** The Abducens nerve (CN VI) exclusively innervates the **Lateral Rectus (LR)** muscle. The primary action of the LR is abduction (moving the eye away from the midline). When this nerve is damaged, the LR fails to contract, leading to an inability to abduct the eye. This results in an "esotropia" (inward deviation) in the primary position, causing horizontal diplopia that worsens when the patient attempts to look toward the side of the lesion. **2. Why the Other Options are Incorrect:** * **Optic Nerve (CN II):** This is a purely sensory nerve responsible for vision and the light reflex. Damage causes vision loss or field defects, not ocular motility issues. * **Oculomotor Nerve (CN III):** This nerve innervates the MR, SR, IR, and IO muscles, as well as the levator palpebrae. A palsy would typically present with "Down and Out" eye positioning, ptosis, and potentially a dilated pupil, rather than isolated abduction failure. * **Trochlear Nerve (CN IV):** This nerve innervates the Superior Oblique. Damage causes **vertical/torsional diplopia** (worse on downgaze and tilting the head toward the lesion), not horizontal diplopia. **Clinical Pearls for NEET-PG:** * **Longest Intracranial Course:** The Abducens nerve has the longest intracranial course, making it highly susceptible to damage from increased intracranial pressure (**False Localizing Sign**). * **Mnemonic:** **LR6SO4** (Lateral Rectus-6, Superior Oblique-4; all others are 3). * **Nuclear Lesion:** A lesion in the Abducens nucleus (in the Pons) results in **ipsilateral horizontal gaze palsy** (inability of both eyes to look toward the lesion) due to involvement of interneurons to the contralateral Medial Rectus.
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