Neuro-Ophthalmology Practice Questions

Q: The given image shows which of the following conditions? (AIIMS Nov 2018)

Inter-nuclear ophthalmoplegia. ***Inter-nuclear ophthalmoplegia*** - The image shows that the **right eye** is **unable to adduct past the midline** when attempting to look left (middle image), which is a classic sign of internuclear ophthalmoplegia (INO). - The **left eye** shows **abducting nystagmus**, a common associated finding in INO due to damage to the **medial longitudinal fasciculus (MLF)**. *Oculomotor nerve palsy* - An oculomotor nerve (CN III) palsy would typically present with a **down-and-out deviation** of the affected eye, **ptosis**, and a **dilated pupil**, which are not seen here. - The patient would also have difficulty moving the eye medially, superiorly, and inferiorly, whereas here the right eye can move down and up, but not fully medially. *Lateral rectus palsy* - A lateral rectus (CN VI) palsy would cause an inability to **abduct** the affected eye and an **esotropia** (eye turning inward) at primary gaze. - The image shows impaired adduction, not abduction, of the right eye, ruling out lateral rectus palsy. *Trochlear nerve palsy* - A trochlear nerve (CN IV) palsy results in weakness of the **superior oblique muscle**, leading to **vertical diplopia**, especially when looking down and in, and a characteristic **head tilt** to compensate. - This presentation does not match the image, which primarily demonstrates a horizontal gaze abnormality with adduction deficit.

Q: The images show a normal optic disc (left) and papilledema with blurred disc margins (right). What is the most common cause of this condition?

ICSOL. ***ICSOL (Intracranial Space-Occupying Lesion)*** - The image on the right depicts **papilledema**, characterized by **blurred optic disc margins**, elevated disc, venous engorgement, and flame-shaped hemorrhages - Papilledema is a classic sign of **raised intracranial pressure** - **Intracranial space-occupying lesions (ICSOL)** such as brain tumors, abscesses, or hematomas are among the most common causes of increased ICP leading to papilledema - The increased pressure is transmitted to the optic nerve sheath, causing optic disc swelling *Malignant Hypertension* - Can cause hypertensive retinopathy with disc swelling, but typically presents with other systemic features (severely elevated BP >180/120 mmHg) - Would show additional retinal changes like cotton-wool spots, exudates, and arteriolar narrowing *Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)* - Causes raised ICP without a mass lesion - More common in obese women of childbearing age - Important differential but ICSOL is more commonly tested as the classic cause *Central Retinal Vein Occlusion (CRVO)* - Causes disc swelling but presents with extensive retinal hemorrhages in all quadrants ("blood and thunder" appearance) - Due to venous obstruction, not raised ICP - Distinct clinical picture from papilledema

Q: The following fundus finding is seen in:

ICSOL. ***ICSOL*** - The image depicts **papilledema**, characterized by a **swollen optic disc** with blurred margins and elevated appearance, often due to increased intracranial pressure. - Increased intracranial pressure commonly results from **Intracranial Space-Occupying Lesions (ICSOLs)** such as tumors, abscesses, or hematomas. *Retinitis pigmentosa* - This condition presents with **pigmentary deposits** (bone spicule appearance) in the peripheral retina and **attenuation of retinal vessels**, which are not seen in the image. - It leads to **progressive vision loss**, initially night blindness, and later tunnel vision. *Multiple sclerosis* - Multiple sclerosis can cause **optic neuritis**, leading to **pale optic disc** due to axonal loss, but not papilledema. - Typically, it involves demyelination in the central nervous system, with various neurological symptoms beyond isolated fundus findings. *Hysterical blindness* - Hysterical blindness (now often referred to as **functional neurological symptom disorder** with visual symptoms) is a diagnosis of exclusion. - It involves normal neurological and funduscopic examinations, including a normal optic disc appearance.

Q: Identify the visual field defect shown in the image.

Bitemporal hemianopia. ***Bitemporal hemianopia*** - The image shows loss of vision in the **temporal (outer) halves of both visual fields**, which is characteristic of bitemporal hemianopia. - This defect typically results from a lesion at the **optic chiasm**, compressing the crossing nasal retinal fibers, often due to a **pituitary tumor**. *Binasal hemianopia* - This condition involves visual loss in the **nasal (inner) halves of both visual fields**, which is the opposite of what is depicted. - It is a rare defect that can be caused by lesions affecting the **uncrossed temporal retinal fibers** on both sides, such as from bilateral carotid artery aneurysms. *Homonymous hemianopia* - A homonymous hemianopia involves the **same half of the visual field in both eyes** (e.g., right visual field loss in both eyes), resulting from a lesion posterior to the optic chiasm. - The image clearly shows different halves affected in each eye (temporal fields), not the same half. *Altitudinal defect* - An altitudinal defect involves the **loss of vision in the upper or lower half of the visual field** in one or both eyes, respecting the horizontal midline. - The visual field loss shown in the image is vertical, affecting the temporal halves, not the upper or lower halves.

Q: A 12-year-old boy is admitted to the emergency department with signs of meningitis. To determine the specific type of meningitis, it is necessary to aspirate cerebrospinal fluid with a lumbar puncture for laboratory examination. However, before performing a lumbar puncture, it must be established that the cerebrospinal fluid pressure is not elevated. What condition in the eye would indicate that cerebrospinal fluid pressure is too elevated for a lumbar puncture to be performed?

Papilledema. ***Papilledema*** - **Papilledema** is **swelling of the optic disc** due to increased intracranial pressure (ICP), which can be visualized during an **ophthalmoscopic examination**. - Performing a **lumbar puncture (LP)** in the presence of papilledema can lead to **brain herniation** due to a sudden drop in pressure below the spinal cord, creating a pressure gradient that forces brain tissue downward. - This is the **primary ocular contraindication** to LP and must be assessed before the procedure. *Retinal hemorrhages at the fovea* - **Retinal hemorrhages** at the fovea are not a direct sign of **increased intracranial pressure (ICP)** in the same way papilledema is. - While certain conditions causing elevated ICP can lead to retinal hemorrhages (e.g., severe hypertension, Terson syndrome), they are not the primary or most reliable indicator for contraindicating an **LP** compared to papilledema. - Retinal hemorrhages can occur from various causes including diabetic retinopathy, retinal vein occlusion, or trauma. *Obvious opacity of the lens* - An **obvious opacity of the lens** refers to a **cataract**. - **Cataracts** are lens opacities that impair vision and are typically associated with aging, trauma, or systemic diseases like diabetes, but not directly with **elevated CSF pressure** or as a contraindication for **LP**. *Separation of the pars optica retinae anterior to the ora serrata* - The **pars optica retinae** refers to the photosensitive posterior part of the retina, and the **ora serrata** is its anterior boundary. - **Separation** in this area might suggest a **retinal detachment** or other structural retinal issue, which is not an indicator of **elevated intracranial pressure (ICP)** and would not contraindicate a **lumbar puncture**.

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

Hyperchromatic iris. ***Hyperchromatic iris*** - The iris in Horner's syndrome typically presents as **heterochromia iridis**, where the affected eye's iris is **hypochromatic (lighter)** compared to the healthy eye due to reduced melanin synthesis from sympathetic denervation - This occurs particularly with congenital or early-onset Horner's syndrome (before age 2 years) - A **hyperchromatic (darker) iris is NOT a feature** of Horner's syndrome, making this the correct answer *Anhidrosis* - **Anhidrosis** (decreased sweating) on the affected side of the face and neck is a classic feature of Horner's syndrome - Results from disruption of postganglionic sympathetic fibers supplying sweat glands in the ipsilateral facial and neck regions - Pattern of anhidrosis helps localize the lesion (central, preganglionic, or postganglionic) *Enophthalmos* - **Mild enophthalmos** (sunken eyeball appearance) occurs in Horner's syndrome - Due to paralysis of **Müller's muscle** (superior tarsal muscle), which normally helps maintain globe position - Combined with ptosis, this creates the characteristic sunken appearance of the affected eye *Miosis* - **Miosis** (pupillary constriction) is a hallmark feature of Horner's syndrome - Results from paralysis of the **iris dilator muscle** due to interrupted sympathetic innervation - Leads to unopposed parasympathetic activity, causing the characteristic small pupil - Dilation lag can be demonstrated with dim lighting or cocaine test

Q: Enlargement of the blind spot occurs in which of the following

Papilledema. ***Papilledema*** - **Papilledema** is swelling of the optic disc due to increased **intracranial pressure**, causing the blind spot to enlarge due to displaced retinal tissue. - This enlargement is a result of the edematous optic nerve head taking up more space on the retina, thus obscuring a larger area where photoreceptors are absent. *Primary open angle glaucoma* - **Primary open-angle glaucoma** causes characteristic **optic nerve damage** and visual field loss, but typically results in arcuate scotomas and peripheral field defects, not an enlarged blind spot. - The damage primarily affects nerve fiber layers, leading to **cupping of the optic disc** and progressive visual field loss without directly expanding the physiological blind spot. *Optic nerve hypoplasia* - **Optic nerve hypoplasia** is a congenital condition where the optic nerve is underdeveloped, leading to a smaller than normal optic disc and often decreased vision. - While it can cause visual field deficits, the blind spot itself is usually normal or even smaller due to the reduced size of the optic disc. *Diabetic macular edema* - **Diabetic macular edema** involves fluid accumulation in the macula, causing blurred or distorted central vision. - It affects the macula, which is responsible for central vision and color perception, and does not directly impact the size or shape of the physiological blind spot.

Question 1

The given image shows which of the following conditions? (AIIMS Nov 2018)

Accepted Answer

Inter-nuclear ophthalmoplegia

Answer

Oculomotor nerve palsy

Answer

Lateral rectus palsy

Answer

Trochlear nerve palsy

Question 2

The images show a normal optic disc (left) and papilledema with blurred disc margins (right). What is the most common cause of this condition?

Accepted Answer

ICSOL

Answer

Malignant hypertension

Answer

Idiopathic intracranial hypertension

Answer

Central retinal vein occlusion

Question 3

The following fundus finding is seen in:

Accepted Answer

ICSOL

Answer

Retinitis pigmentosa

Answer

Multiple sclerosis

Answer

Hysterical blindness

Question 4

Identify the visual field defect shown in the image.

Accepted Answer

Bitemporal hemianopia

Answer

Binasal hemianopia

Answer

Homonymous hemianopia

Answer

Altitudinal defect

Question 5

A 27-year-old female patient presents with sudden diminishing vision associated with a relative afferent pupillary defect in the right eye. On examination, the left eye is normal.

Which of the following combinations of investigations would be most appropriate?

Accepted Answer

MRI brain and orbits + Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Visual evoked potentials

Answer

Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Blood tests

Question 6

A 12-year-old boy is admitted to the emergency department with signs of meningitis. To determine the specific type of meningitis, it is necessary to aspirate cerebrospinal fluid with a lumbar puncture for laboratory examination. However, before performing a lumbar puncture, it must be established that the cerebrospinal fluid pressure is not elevated. What condition in the eye would indicate that cerebrospinal fluid pressure is too elevated for a lumbar puncture to be performed?

Accepted Answer

Papilledema

Answer

Retinal hemorrhages at the fovea

Answer

Obvious opacity of the lens

Answer

Separation of the pars optica retinae anterior to the ora serrata

Question 7

Most common optic nerve tumor in children causing blindness:

Accepted Answer

Glioma

Answer

Astrocytoma

Answer

Craniopharyngioma

Answer

Meningioma

Question 8

A case of injury to right brow due to a fall from scooter presents with sudden loss of vision in the right eye. The pupil shows absent direct reflex but a normal consensual pupillary reflex is present. The fundus is normal. The treatment of choice is:

Accepted Answer

Intensive intravenous corticosteroids as prescribed for spinal injuries to be instituted within six hours

Answer

Pulse methyl Prednisolone 250 mg four times daily for three days

Answer

Emergency optic canal decompression

Answer

Oral Prednisolone 1.5 mg/kg body weight

Question 9

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

Accepted Answer

Hyperchromatic iris

Answer

Anhidrosis

Answer

Enophthalmos

Answer

Miosis

Question 10

Enlargement of the blind spot occurs in which of the following

Accepted Answer

Papilledema

Answer

Primary open angle glaucoma

Answer

Optic nerve hypoplasia

Answer

Diabetic macular edema

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

On this page

Practice by Chapter

Want unlimited practice?