Neuro-Ophthalmology Practice Questions

Q: Foster Kennedy syndrome is associated with which of the following conditions?

Frontal lobe tumor. **Explanation:** **Foster Kennedy Syndrome** is a classic neuro-ophthalmological triad caused by a space-occupying lesion (SOL), most commonly a **frontal lobe tumor** (e.g., olfactory groove meningioma). The syndrome occurs due to the tumor's physical location and its effect on intracranial pressure (ICP). 1. **Why Frontal Lobe Tumor is Correct:** * **Ipsilateral Optic Atrophy:** Direct compression of the optic nerve by the tumor leads to primary optic atrophy on the same side as the lesion. * **Contralateral Papilledema:** As the tumor grows, it increases ICP, which manifests as papilledema in the opposite eye (where the nerve is not yet compressed). * **Anosmia:** Often present due to pressure on the olfactory bulb. 2. **Why Other Options are Incorrect:** * **A. Anterior Ischemic Optic Neuropathy (AION):** While "Pseudo-Foster Kennedy Syndrome" can occur (where one eye has old optic atrophy from a previous AION and the other has acute disc edema from a new AION), it is not associated with increased ICP or frontal tumors. * **B & D. Retinal Detachment / Macular Edema:** These are primary retinal pathologies and do not involve the intracranial pressure mechanisms or the specific optic nerve patterns seen in this syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudo-Foster Kennedy Syndrome:** The most common cause is bilateral sequential AION. It lacks the anosmia and raised ICP seen in the true syndrome. * **Kennedy’s Triad:** 1. Ipsilateral optic atrophy, 2. Contralateral papilledema, 3. Ipsilateral anosmia. * **Most Common Tumor:** Olfactory groove meningioma is the top differential, followed by frontal lobe gliomas.

Q: The most common ocular motility problem in thyroid myopathy is due to involvement of which muscle?

Inferior rectus. **Explanation:** Thyroid Eye Disease (TED), also known as Graves’ Ophthalmopathy, is characterized by an autoimmune-mediated inflammatory infiltration of the extraocular muscles. This leads to muscle enlargement and subsequent fibrosis, resulting in restrictive strabismus. **1. Why Inferior Rectus is Correct:** The involvement of extraocular muscles in TED follows a specific, high-yield sequence often remembered by the mnemonic **"I’M SLOW"**: * **I**nferior Rectus (Most common) * **M**edial Rectus * **S**uperior Rectus * **L**ateral Rectus * **O**blique muscles (Least common) The **Inferior Rectus** is the most frequently affected muscle (60-70% of cases). Fibrosis of this muscle prevents the eye from looking upward, leading to a restrictive vertical squint and the characteristic "upshot" limitation. **2. Why Other Options are Incorrect:** * **Medial Rectus:** This is the second most common muscle involved. Its involvement leads to esotropia (inward deviation) and limited abduction. * **Superior Rectus:** While frequently involved, it is less common than the inferior and medial recti. * **Inferior Oblique:** The oblique muscles are the least likely to be affected in the early or typical stages of thyroid myopathy. **Clinical Pearls for NEET-PG:** * **Pathology:** The primary change is the deposition of glycosaminoglycans (GAGs) and water in the muscle belly, while the **tendons are typically spared** (a key radiological feature distinguishing it from orbital pseudotumor). * **Clinical Sign:** **Dalrymple sign** (lid retraction in primary gaze) is the most common clinical sign of TED. * **Diagnosis:** Contrast-enhanced CT or MRI of the orbit shows "coke-bottle" appearance of the enlarged muscle bellies.

Q: Wernicke's hemianopic pupillary response is seen in lesions at which location?

Optic tract. **Wernicke’s Hemianopic Pupil** is a clinical sign seen in lesions of the **Optic Tract**. ### 1. Why Optic Tract is Correct The optic tract carries both visual fibers and pupillary light reflex fibers (which leave the tract before the Lateral Geniculate Body to reach the Pretectal nucleus). In an optic tract lesion, there is a contralateral homonymous hemianopia. If a fine beam of light is shone on the **non-functioning (blind) half** of the retina, there is **no pupillary response** because the reflex arc is interrupted. If light is shone on the **functioning half** of the retina, the pupil **constricts normally**. This disparity is Wernicke’s pupillary sign. ### 2. Why Other Options are Incorrect * **Optic Chiasma:** Lesions here typically cause bitemporal hemianopia. While pupillary fibers are present, the specific "hemianopic" disparity described by Wernicke is not the classic presentation. * **Lateral Geniculate Body (LGB):** The pupillary fibers exit the visual pathway *before* reaching the LGB. Therefore, lesions at or beyond the LGB (like the optic radiation) will cause visual field defects but will have **normal pupillary light reflexes**. * **Optic Radiation:** As mentioned above, these are post-LGB structures. Lesions here result in hemianopia with a **brisk/normal** pupillary response. ### 3. Clinical Pearls for NEET-PG * **Wernicke’s Pupil = Pre-LGB lesion** (specifically Optic Tract). * **Light-Near Dissociation:** If a patient has a pupillary defect but the near reflex is intact, think of Argyll Robertson Pupil (Neurosyphilis) or Adie’s Tonic Pupil. * **Bebe’s Rule:** In optic tract lesions, you may also see a **Relative Afferent Pupillary Defect (RAPD)** in the eye with the temporal field loss (contralateral to the lesion) because the nasal retina (which serves the temporal field) has more crossed fibers than uncrossed fibers.

Q: According to the Optic Neuritis Treatment Trial (ONTT), which treatment modality was associated with the highest rate of recurrence?

Oral prednisone alone. The **Optic Neuritis Treatment Trial (ONTT)** is a landmark study in neuro-ophthalmology that established the standard of care for acute demyelinating optic neuritis. ### Why Oral Prednisone alone is the correct answer: The ONTT revealed a paradoxical finding: patients treated with **low-dose oral prednisone (1 mg/kg/day) alone** had a **two-fold higher rate of recurrence** of optic neuritis (in either the same or the contralateral eye) compared to the intravenous steroid group or the placebo group. Consequently, oral prednisone in standard doses is now **contraindicated** as a starting monotherapy for optic neuritis. ### Analysis of Incorrect Options: * **A & C (IV Methylprednisolone):** The trial showed that high-dose IV methylprednisolone (followed by oral tapering) **speeded up the rate of visual recovery** but did not improve the final visual outcome at one year. Crucially, it did not increase the risk of recurrence and was found to delay the onset of Multiple Sclerosis (MS) for the first two years. * **D (Observation):** Patients in the observation/placebo group had a lower rate of recurrence than those in the oral prednisone group. While observation is an option for mild cases, it is not associated with the "highest" recurrence rate. ### NEET-PG High-Yield Pearls: * **Standard Treatment:** IV Methylprednisolone (1g/day for 3 days) followed by Oral Prednisone (1mg/kg/day for 11 days). * **Visual Prognosis:** Most patients recover to 20/40 vision or better, regardless of treatment. * **MRI Significance:** The strongest predictor of developing MS after optic neuritis is the presence of **white matter lesions** on the initial brain MRI. * **Classic Sign:** Relative Afferent Pupillary Defect (RAPD) is the most common objective finding.

Question 1

Which of the following is NOT true regarding Homer's syndrome?

Accepted Answer

Apparent exophthalmos

Answer

Miosis

Answer

Anhydrosis

Answer

Hyperchromatic iris

Question 2

Foster Kennedy syndrome is associated with which of the following conditions?

Accepted Answer

Frontal lobe tumor

Answer

Anterior ischemic optic neuropathy (AION)

Answer

Retinal detachment

Answer

Macular edema

Question 3

The most common ocular motility problem in thyroid myopathy is due to involvement of which muscle?

Accepted Answer

Inferior rectus

Answer

Medial rectus

Answer

Superior rectus

Answer

Inferior oblique

Question 4

On touching the cornea of the right eye, only the right eye blinks. The same response is observed on touching the left eye. Where is the lesion located?

Accepted Answer

Left 5th nerve palsy

Answer

Left 7th nerve palsy

Answer

Optic nerve palsy

Answer

Left 3rd nerve palsy

Question 5

Which of the following conditions does NOT typically affect vision?

Accepted Answer

Papilloedema

Answer

Keratitis

Answer

Optic neuritis

Answer

Retinoblastoma

Question 6

In uraemic amaurosis, what is the typical appearance of the pupils?

Accepted Answer

Dilated but reactive to light

Answer

Constricted

Answer

Dilated and non-reactive to light

Answer

Normal

Question 7

A lesion causing grossly incongruous, incomplete contralateral homonymous hemianopia is located in which of the following?

Accepted Answer

Lateral optic chiasma

Answer

Optic nerve

Answer

Central optic chiasma

Answer

Optic tract

Question 8

Wernicke's hemianopic pupillary response is seen in lesions at which location?

Accepted Answer

Optic tract

Answer

Optic chiasma

Answer

Optic radiation

Answer

Lateral geniculate body

Question 9

A child presents with sudden loss of vision with painful ocular movements. The eye is white and there are no obvious signs on ophthalmoscopy. What is the most likely diagnosis?

Accepted Answer

Retrobulbar neuritis

Answer

Optic nerve glioma

Answer

Craniopharyngioma

Answer

Eales disease

Question 10

According to the Optic Neuritis Treatment Trial (ONTT), which treatment modality was associated with the highest rate of recurrence?

Accepted Answer

Oral prednisone alone

Answer

Intravenous methylprednisolone alone

Answer

Intravenous methylprednisolone and oral prednisone

Answer

Observation

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

On this page

Practice by Chapter

Want unlimited practice?