Neuro-Ophthalmology Practice Questions

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.

Q: Which test is used to detect a relative afferent pupillary defect (RAPD)?

Swinging flashlight test. ***Swinging flashlight test*** - The **swinging flashlight test** is the classic and most reliable method to detect a **relative afferent pupillary defect (RAPD)**. - It involves alternately shining a light into each eye, observing for unequal pupillary constriction and dilation, which indicates a defect in the afferent visual pathway of the affected eye. *Tonometry* - **Tonometry** is used to measure **intraocular pressure**, which is important for detecting and monitoring conditions like glaucoma. - It does not assess pupillary function or the integrity of the afferent visual pathway. *Slit-lamp examination* - A **slit-lamp examination** provides a magnified view of the anterior and posterior segments of the eye, helping to identify various ocular diseases like cataracts or uveitis. - While it can reveal structural abnormalities, it is not designed to detect an RAPD. *Perimetry* - **Perimetry**, also known as visual field testing, assesses the extent of a person's **field of vision** and can detect visual field defects. - It is used to evaluate the function of the retina and optic nerve but does not directly measure pupillary responses or an RAPD.

Q: All of the following are seen in 3rd nerve palsy except

Loss of abduction. ***Loss of abduction*** - The **lateral rectus muscle**, responsible for **abduction** of the eye, is innervated by the **abducens nerve (CN VI)**, not the oculomotor nerve (CN III). - Therefore, a third nerve palsy would not directly cause a loss of abduction. *Ptosis* - **Ptosis** (drooping of the upper eyelid) is a common finding in **CN III palsy** due to paralysis of the **levator palpebrae superioris muscle**. - This muscle is innervated by the oculomotor nerve. *Pupillary dilatation* - The **oculomotor nerve (CN III)** carries **parasympathetic fibers** that constrict the pupil. - Damage to these fibers in a CN III palsy results in **unopposed sympathetic activity**, leading to a dilated pupil that is poorly reactive to light. *Exotropia and hypotropia* - **Exotropia** (eye turned outward) occurs due to unopposed action of the **lateral rectus muscle**. - **Hypotropia** (eye turned downward) is due to the unopposed action of the **superior oblique muscle**.

Q: A 50-year-old woman presents with progressive visual loss in her right eye and pain with eye movements. An MRI shows optic nerve enhancement. Which condition is most likely?

Optic neuritis. ***Optic neuritis*** - **Progressive visual loss** and **pain with eye movements** are classic symptoms of optic neuritis, an inflammatory demyelinating condition of the optic nerve. - **Optic nerve enhancement** on MRI confirms inflammation of the optic nerve, highly characteristic of optic neuritis. *Retinal detachment* - Symptoms typically include a **sudden onset of flashes, floaters**, and a **"curtain" or "shadow"** in the visual field, not usually pain with eye movement. - Diagnosis is made by **ophthalmoscopy** showing the detached retina, not optic nerve enhancement on MRI. *Acute angle-closure glaucoma* - Presents with **sudden severe eye pain, headache, blurred vision, halos** around lights, and a **red eye** with a fixed, dilated pupil. - The elevated **intraocular pressure** is the key feature, and it does not typically show optic nerve enhancement on MRI. *Central retinal artery occlusion* - Characterized by **sudden, painless, severe vision loss** in one eye, often described as a "stroke of the eye." - Ophthalmoscopy reveals a **"cherry-red spot"** on the fovea with retinal whitening, and there is no associated pain with eye movement or optic nerve enhancement.

Q: A patient presents with vertical diplopia and a head tilt. What is the most likely cause?

Superior oblique palsy. ***Superior oblique palsy*** - A **superior oblique muscle palsy** characteristically causes **vertical diplopia** and a compensatory **head tilt away** from the affected eye to align the visual axes. - The superior oblique muscle is innervated by the **trochlear nerve (CN IV)**, and its primary actions are **intorsion**, depression, and abduction of the eye. - This is diagnosed using the **Parks-Bielschowsky three-step test**: vertical deviation increases on contralateral gaze and ipsilateral head tilt. *Medial rectus palsy* - A **medial rectus palsy** primarily causes **horizontal diplopia**, as it impairs the eye's ability to adduct (move inward). - This condition is typically associated with a **third cranial nerve (oculomotor nerve) lesion** and would not cause vertical diplopia or head tilt. *Lateral rectus palsy* - A **lateral rectus palsy** results in **horizontal diplopia**, as it prevents the eye from abducting (moving outward). - This is caused by a **sixth cranial nerve (abducens nerve) lesion** and would not present with vertical diplopia or head tilt. *Inferior rectus palsy* - An **inferior rectus palsy** would primarily affect the **depression** and **extorsion** of the eye, causing vertical diplopia. - However, the pattern differs from superior oblique palsy: it does not typically produce the same characteristic compensatory head tilt pattern. - This condition is also associated with a **third cranial nerve (oculomotor nerve) lesion**.

Q: Which of the following visual defects is most commonly associated with papilloedema?

Enlarged blind spot. ***Enlarged blind spot*** - Papilloedema is **swelling of the optic disc** due to increased intracranial pressure, which causes compression of the optic nerve fibers. - This compression primarily affects the axons originating from the **optic nerve head**, leading to an expansion of the physiological blind spot on visual field testing. *Homonymous hemianopia* - This visual field defect involves loss of vision in the **same half of the visual field** in both eyes, and is typically caused by lesions **posterior to the optic chiasm**. - It is not directly caused by papilloedema, which affects the optic nerve head itself. *Amaurosis fugax* - This refers to a **transient, monocular loss of vision** that often lasts for a few minutes, usually due to **retinal ischemia** (e.g., from an embolus). - While it represents a visual disturbance, it is distinct from the chronic, pressure-induced changes seen in papilloedema. *Homonymous quadrantanopia* - This is a loss of vision in **one quadrant of the visual field** in both eyes, also typically resulting from lesions in the **retrochiasmal visual pathways** (e.g., parietal or temporal lobe). - Like homonymous hemianopia, it is a cortical or subcortical lesion and not a direct consequence of optic disc swelling.

Q: What condition is primarily detected using illuminated Frenzel glasses?

Nystagmus. ***Nystagmus*** - Illuminated Frenzel glasses **prevent visual fixation** and magnify the eyes, thereby unmasking and enhancing the observation of nystagmus. - This allows for the detection of subtle or latent nystagmus that might be suppressed by visual fixation in a normal examination. *Heterophoria* - Heterophoria is a **latent deviation of the eyes** that is only apparent when fusion is broken. - While Frenzel glasses prevent fixation, they are primarily used to observe eye movements, not specifically to measure or diagnose heterophoria, which is typically found using **cover-uncover tests** or other specialized techniques. *Esotropia* - Esotropia is a type of **strabismus** where one or both eyes turn inward. - This condition is typically visible on gross inspection or can be confirmed with **cover-uncover tests** or other objective measures of ocular alignment, not primarily with Frenzel glasses. *Astigmatism* - Astigmatism is an optical defect that results in blurred vision due to the inability of the eye to focus light equally on the retina across different axes. - It is diagnosed by **refraction methods** using an autorefractor, retinoscopy, or subjective refraction, not by observing eye movements with Frenzel glasses.

Question 1

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 2

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 3

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

Accepted Answer

Hyperchromatic iris

Answer

Anhidrosis

Answer

Enophthalmos

Answer

Miosis

Question 4

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

Question 5

Which test is used to detect a relative afferent pupillary defect (RAPD)?

Accepted Answer

Swinging flashlight test

Answer

Tonometry

Answer

Slit-lamp examination

Answer

Perimetry

Question 6

All of the following are seen in 3rd nerve palsy except

Accepted Answer

Loss of abduction

Answer

Ptosis

Answer

Pupillary dilatation

Answer

Exotropia and hypotropia

Question 7

A 50-year-old woman presents with progressive visual loss in her right eye and pain with eye movements. An MRI shows optic nerve enhancement. Which condition is most likely?

Accepted Answer

Optic neuritis

Answer

Retinal detachment

Answer

Acute angle-closure glaucoma

Answer

Central retinal artery occlusion

Question 8

A patient presents with vertical diplopia and a head tilt. What is the most likely cause?

Accepted Answer

Superior oblique palsy

Answer

Medial rectus palsy

Answer

Lateral rectus palsy

Answer

Inferior rectus palsy

Question 9

Which of the following visual defects is most commonly associated with papilloedema?

Accepted Answer

Enlarged blind spot

Answer

Homonymous hemianopia

Answer

Amaurosis fugax

Answer

Homonymous quadrantanopia

Question 10

What condition is primarily detected using illuminated Frenzel glasses?

Accepted Answer

Nystagmus

Answer

Heterophoria

Answer

Esotropia

Answer

Astigmatism

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

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