Neuro-Ophthalmology Practice Questions

Q: What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Horner syndrome. No changes were made to the text as none of the provided references reached the relevance threshold of 7/10 for the specific topic of Horner syndrome diagnosis and its differentials. The provided references largely discussed coagulation (mislabeled chapters), neurological signs of intracranial pressure, or general pupillary reflexes without specific diagnostic criteria for Horner syndrome or its differentiating features like anhidrosis.

Q: A patient presents with right-sided field defects in both eyes, but central vision remains unaffected. What is the most likely diagnosis?

Homonymous Hemianopia with Macular Sparing. ***Homonymous Hemianopia with Macular Sparing*** - **Homonymous hemianopia** refers to a visual field defect on the same side in both eyes (in this case, the right side), which precisely matches the patient's presentation. - **Macular sparing** occurs because the occipital pole, which processes central vision, often has a dual blood supply from both the **posterior cerebral artery (PCA)** and the **middle cerebral artery (MCA)**, protecting it during a stroke affecting one vessel. *Heteronymous Hemianopia with Central Sparing* - **Heteronymous hemianopia** involves defects on opposite sides of the visual field in each eye (e.g., loss of both temporal fields), which is inconsistent with the patient's right-sided defect in both eyes. - This type of defect is classically caused by a lesion at the **optic chiasm**, such as a pituitary adenoma, leading to **bitemporal hemianopia**. *Optic Chiasm Lesion* - A lesion compressing the optic chiasm, where the nasal retinal fibers cross, typically causes **bitemporal hemianopia** (loss of peripheral vision in both eyes). - This results in a **heteronymous** defect, not a **homonymous** one as described in the question. *Optic Tract Lesion* - A lesion in the optic tract (posterior to the chiasm) does cause a contralateral **homonymous hemianopia**. - However, lesions in the optic tract typically do not spare the macula, as the fibers from the macula are intermingled with other fibers at this point. Macular sparing points towards a more posterior lesion in the **visual cortex**.

Q: Which of the following is NOT a feature of Horner's Syndrome?

Exophthalmos. ***Exophthalmos*** - **Exophthalmos** (bulging of the eyeball) is caused by hyperactivity of the sympathetic system (e.g., in *hyperthyroidism*) or orbital mass effects, making it *NOT* a feature of sympathetic paralysis. - Horner's Syndrome, due to paralysis of the **Müller's muscle** in the orbit, actually causes the opposite effect: apparent **enophthalmos** (sinking of the eyeball). *Anhidrosis* - **Anhidrosis** (lack of sweating) on the ipsilateral face and neck is a crucial component of Horner's syndrome, particularly if the lesion is located preganglionic or centrally. - This occurs because the sympathetic fibers supplying the **sweat glands** are disrupted along the pathway. *Miosis* - **Miosis** (constricted pupil) is a hallmark feature resulting from the unopposed action of the parasympathetic system's **sphincter pupillae muscle**. - The sympathetic nerves responsible for innervating the **dilator pupillae muscle** are paralyzed, leading to relative pupil constriction that is more pronounced in dim light (*anisocoria*). *Ptosis* - **Ptosis** (droopy eyelid) is a characteristic symptom caused by the paralysis of the sympathetically innervated **Müller's muscle** (superior tarsal muscle). - This results in a mild degree of eyelid drooping (partial ptosis), often less severe than the ptosis seen with **Oculomotor Nerve (CN III) palsy**.

Q: Which of the following is the diagnosis based on the given eye movement abnormality image?

Internuclear ophthalmoplegia. **Internuclear ophthalmoplegia** - This diagnosis is indicated by the failure of the right eye to **adduct** (move inwards) when looking to the left, which is a hallmark sign. This specific defect is caused by a lesion in the **Medial Longitudinal Fasciculus (MLF)** on the same side as the adduction failure. - Another key feature shown is **nystagmus** in the contralateral (left) eye during **abduction** (outward movement). This combination of ipsilateral adduction failure and contralateral abducting nystagmus is classic for INO. *3rd nerve palsy* - A 3rd nerve palsy would present with the affected eye positioned 'down and out' due to unopposed action of the superior oblique and lateral rectus muscles. It also typically involves **ptosis** and a **dilated pupil**. - In the given image, the vertical movements and pupillary function are not depicted as abnormal, and the primary issue is with horizontal conjugate gaze, not the multiple deficits seen in 3rd nerve palsy. *6th nerve palsy* - This condition results in the inability to **abduct** the eye (move it outwards) due to paralysis of the **lateral rectus muscle**. The patient would complain of horizontal diplopia, worse on gaze towards the affected side. - The image shows that both eyes are capable of abduction. The defect is clearly in adduction of the right eye. *Horizontal gaze palsy* - This involves the inability of **both eyes** to move in one horizontal direction. It is caused by a lesion in the pontine gaze center, the **Paramedian Pontine Reticular Formation (PPRF)**. - In this case, the left eye successfully moves to the left, and both eyes can move to the right, ruling out a complete gaze palsy to either side.

Q: A child has been diagnosed with cavernous sinus meningioma. Which of these is correct?

Ptosis-left eye. ***Ptosis-left eye*** - The image clearly shows **drooping of the upper eyelid** of the left eye, which is the definition of **ptosis**. - A cavernous sinus meningioma can compress the **oculomotor nerve (III cranial nerve)**, which innervates the **levator palpebrae superioris muscle** responsible for lifting the eyelid, leading to ptosis. *Phthisis bulbi-right eye* - **Phthisis bulbi** refers to a shrunken, non-functional eye, which is not depicted in this image; the right eye appears to be normally sized and open. - The patient's right eye is wide open and visually functional, contrasting with the shrunken appearance characteristic of phthisis bulbi. *Exophthalmos-right eye* - **Exophthalmos** is the bulging of the eyeball, but the right eye in the image appears to be in its normal position within the orbit. - There are no signs of abnormal protrusion of the right eye, whereas exophthalmos would present as a noticeable forward displacement. *Bell sign-left eye* - **Bell's phenomenon** is the upward and outward rotation of the eyeball when attempting to close the eyelids, typically seen in facial nerve palsy. - The image shows a static drooping eyelid, not the dynamic movement associated with Bell's phenomenon, and the issue is related to the eyelid position itself rather than attempted closure against facial nerve weakness.

Q: The following image shows:

Lisch nodules. ***Lisch nodules*** - The image displays multiple, small, well-defined, yellowish-brown lesions on the **iris**, which are characteristic of **Lisch nodules**. - These are **melanocytic hamartomas** of the iris, pathognomonic for **Neurofibromatosis type 1 (NF1)**. *Koeppe nodules* - These are small, grayish-white nodules that appear at the **pupillary margin** of the iris, typically seen in **uveitis**. - They are composed of inflammatory cells and are often a sign of active inflammation, differentiating them from the pigmented Lisch nodules. *Busacca nodules* - These are larger, typically yellowish-white nodules located on the **surface of the iris**, away from the pupillary margin, also associated with **granulomatous uveitis**. - Unlike Lisch nodules, they are usually inflammatory and not pigmented hamartomas. *Dalen-Fuchs nodules* - These are deposits of inflammatory cells and altered retinal pigment epithelium located in the **choroid or retina**, beneath the retinal pigment epithelium. - They are seen in conditions like **sympathetic ophthalmia** and **Vogt-Koyanagi-Harada (VKH) disease**, not on the iris surface.

Q: Which is the most likely diagnosis of this patient?

Horner's syndrome left. ***Horner's syndrome left*** - The image clearly shows **ptosis** (drooping eyelid) on the left eye, which is a classic feature of Horner's syndrome. - Additionally, there appears to be **miosis** (constricted pupil) on the left side compared to the right, another key component of Horner's syndrome. *Bell's palsy right* - Bell's palsy involves **facial muscle weakness or paralysis**, typically affecting the entire half of the face, including inability to close the eye or raise the eyebrow. - The image does not show signs of widespread facial paralysis; the primary findings are confined to the left eye. *Unilateral exophthalmos* - **Exophthalmos** is the bulging of the eye out of the orbit. - The image demonstrates the opposite effect on the left eye, with the eyelid drooping and the eye appearing less prominent, not bulging. *Anisocoria* - **Anisocoria** refers to unequal pupil sizes, which is present here (miosis on the left). - However, anisocoria is a *symptom* that can be part of many conditions, including Horner's syndrome, but it does not encompass the additional finding of **ptosis** seen in the image.

Q: What is the diagnosis based on this fundus examination?

Papilledema. ***Papilledema*** - The image shows a **swollen optic disc** with blurred margins, loss of the optic cup, and **hemorrhages** on and around the disc, all characteristic features of papilledema. - **Papilledema** is swelling of the optic disc due to increased intracranial pressure. *Optic atrophy* - **Optic atrophy** typically presents with a **pale optic disc**, sharply defined margins, and a reduction in the number of retinal nerve fibers. - There is no evidence of disc pallor or sharp margins in the provided image; instead, there is significant disc swelling and blurring. *Cupping of the disk* - **Cupping of the disc** refers to an enlargement of the physiological optic cup, often seen in glaucoma where there is a backward displacement of the lamina cribrosa. - The image clearly shows **loss of the optic cup** due to swelling, not an enlargement of it. *Silver wire appearance* - The **silver wire appearance** refers to a prominent light reflex off the blood column in retinal arterioles, indicating severe arterial narrowing and sclerosis, typically seen in advanced hypertensive retinopathy. - The primary findings in this image relate to the optic disc and surrounding tissue, not the general appearance of the retinal arterioles.

Question 1

What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Accepted Answer

Horner syndrome

Answer

Argyll Robertson pupil

Answer

Marcus Gunn pupil

Answer

Adie's tonic pupil

Question 2

A patient presents with right-sided field defects in both eyes, but central vision remains unaffected. What is the most likely diagnosis?

Accepted Answer

Homonymous Hemianopia with Macular Sparing

Answer

Optic Tract Lesion

Answer

Heteronymous Hemianopia with Central Sparing

Answer

Optic Chiasm Lesion

Question 3

Which of the following is NOT a feature of Horner's Syndrome?

Accepted Answer

Exophthalmos

Answer

Miosis

Answer

Ptosis

Answer

Anhidrosis

Question 4

Which of the following is the diagnosis based on the given eye movement abnormality image?

Accepted Answer

Internuclear ophthalmoplegia

Answer

3rd nerve palsy

Answer

6th nerve palsy

Answer

Horizontal gaze palsy

Question 5

In optic neuritis, which is true?

Accepted Answer

Unilateral vision loss, pain on eye movement, and decreased color vision

Answer

Unilateral vision loss with decreased color vision

Answer

Pain on eye movement only

Answer

Bilateral vision loss is common

Question 6

A 20-year-old woman is admitted with the following presentation. 1% pilocarpine is not showing any response on the side of mydriasis. What is the diagnosis? (Recent NEET Pattern 2016-17)

Accepted Answer

Pharmacological block

Answer

Diabetic neuropathy

Answer

Uncal herniation

Answer

Adie tonic pupil

Question 7

A child has been diagnosed with cavernous sinus meningioma. Which of these is correct?

Accepted Answer

Ptosis-left eye

Answer

Phthisis bulbi-right eye

Answer

Exophthalmos-right eye

Answer

Bell sign-left eye

Question 8

The following image shows:

Accepted Answer

Lisch nodules

Answer

Koeppe nodules

Answer

Busacca nodules

Answer

Dalen-Fuchs nodules

Question 9

Which is the most likely diagnosis of this patient?

Accepted Answer

Horner's syndrome left

Answer

Bell's palsy right

Answer

Unilateral exophthalmos

Answer

Anisocoria

Question 10

What is the diagnosis based on this fundus examination?

Accepted Answer

Papilledema

Answer

Optic atrophy

Answer

Cupping of the disc

Answer

Silver wire appearance

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

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