Neuro-Ophthalmology Practice Questions

Q: Binasal hemianopia is seen in which of the following conditions?

Bilateral lateral chiasma lesions. ### Explanation **1. Why Option C is Correct:** Binasal hemianopia is a rare visual field defect where the nasal half of the visual field is lost in both eyes. To understand this, remember that the **nasal visual field** projects onto the **temporal (lateral) retina**. The nerve fibers from the temporal retina do not decussate; they pass through the **lateral aspects of the optic chiasm**. Therefore, bilateral compression or lesions of the lateral chiasma (e.g., due to calcified internal carotid arteries or bilateral glaucoma) result in binasal hemianopia. **2. Analysis of Incorrect Options:** * **Option A (Optic nerve lesions):** These typically result in ipsilateral monocular blindness or a central scotoma, not a hemianopia affecting both eyes. * **Option B (Central chiasma lesions):** This is the classic site for **Bitemporal hemianopia**. Lesions here (like Pituitary Adenoma) compress the decussating nasal retinal fibers, which carry information from the temporal visual fields. * **Option D (Optic tract lesion):** Lesions posterior to the chiasm (optic tract, lateral geniculate body, or optic radiations) result in **Contralateral Homonymous Hemianopia**. **3. Clinical Pearls for NEET-PG:** * **Bitemporal Hemianopia:** Most common chiasmal syndrome; caused by Pituitary Adenoma (from below) or Craniopharyngioma (from above). * **Binasal Hemianopia:** Often associated with **bilateral internal carotid artery (ICA) atherosclerosis** or distension of the third ventricle. * **Rule of Thumb:** Lesions **at** the chiasm cause heteronymous defects (Bitemporal/Binasal); lesions **behind** the chiasm cause homonymous defects. * **Foster Kennedy Syndrome:** Optic atrophy in one eye (compression) and papilledema in the other (increased ICP), often due to frontal lobe tumors.

Q: Bilateral retrobulbar neuritis occurs in:

Both of the above. **Explanation:** Retrobulbar neuritis (RBN) is a form of optic neuritis where the inflammation occurs behind the globe, resulting in a normal-looking optic disc initially ("the patient sees nothing, and the doctor sees nothing"). While often unilateral, bilateral involvement is a classic feature of specific demyelinating and inflammatory conditions. 1. **Multiple Sclerosis (MS):** This is the most common cause of optic neuritis. While it typically presents as a unilateral event, it can occur bilaterally, either simultaneously (rare in adults, more common in children) or sequentially (one eye followed by the other over time). 2. **Neuromyelitis Optica (NMO/Devic’s Disease):** NMO is characterized by the triad of optic neuritis and transverse myelitis. Unlike MS, the optic neuritis in NMO is frequently **bilateral**, more severe, and often results in poorer visual recovery. It is strongly associated with the **AQP4-IgG antibody**. **Why "Both of the above" is correct:** Both MS and NMO are primary demyelinating diseases of the Central Nervous System that target the optic nerve. Therefore, both can manifest as bilateral retrobulbar neuritis. **Clinical Pearls for NEET-PG:** * **Marcus Gunn Pupil (RAPD):** The most important clinical sign in unilateral or asymmetric bilateral optic neuritis. * **Pulfrich Phenomenon:** Altered perception of motion (objects moving in a straight line appear to move in ellipses). * **Uhthoff’s Phenomenon:** Temporary worsening of vision with increased body temperature (e.g., after a hot shower or exercise). * **Uthoff's vs. Lhermitte's:** Do not confuse Uhthoff’s with **Lhermitte’s sign** (an electric shock-like sensation down the spine on neck flexion, also seen in MS). * **Treatment:** The **Optic Neuritis Treatment Trial (ONTT)** established that IV Methylprednisolone hastens recovery, while oral steroids alone may increase the risk of recurrence.

Q: A spiral field defect is a characteristic feature of which condition?

Hysterical amblyopia. ### Explanation **Correct Answer: B. Hysterical amblyopia** **Understanding the Concept:** A **spiral field defect** is a non-organic visual field loss typically seen in **Hysterical amblyopia** (a conversion disorder). During kinetic perimetry (Goldmann), as the stimulus is moved repeatedly from the periphery to the center, the patient reports seeing the object at progressively smaller diameters in each successive circle. This results in a continuous inward spiraling of the plotted points, which is physiologically impossible. It occurs due to psychological fatigue or subconscious suggestion during the examination. **Analysis of Incorrect Options:** * **A. Amblyopia exanopsia:** This is "disuse" amblyopia (e.g., from a cataract or ptosis). It typically presents with decreased visual acuity rather than specific field defects like a spiral. * **C. Malingering:** While also non-organic, malingerers (who deliberately feign illness for gain) more commonly demonstrate a **tubular (tunnel) field defect**, where the field size remains constant regardless of the distance from the screen (violating the laws of physics/optics). * **D. Toxic amblyopia:** Usually caused by tobacco, alcohol, or drugs (e.g., Ethambutol). It characteristically presents with **centrocecal scotomas** and color vision defects, not a spiral pattern. **Clinical Pearls for NEET-PG:** * **Tubular vs. Spiral:** Both are non-organic. **Spiral** is classic for Hysteria; **Tubular** (constant diameter at 1m and 2m) is classic for Malingering. * **Star-shaped field:** Another variation of the non-organic field where the points crisscross irregularly. * **Key Diagnostic Tool:** The confrontation test or tangent screen (Bjerrum screen) is used to differentiate organic from non-organic "tunnel vision." In organic disease (e.g., Glaucoma or Retinitis Pigmentosa), the field **expands** as the patient moves further from the screen.

Q: A young man presents with blurring of vision in the right eye, followed by the left eye after 3 months. Examination reveals disc hyperemia, edema, circumpapillary telangiectasia with normal pupillary response and centrocecal scotoma on perimetry. What is the most likely cause?

Leber's hereditary optic neuropathy. ### Explanation **Correct Answer: D. Leber's Hereditary Optic Neuropathy (LHON)** **Why it is correct:** LHON is a mitochondrially inherited degeneration of retinal ganglion cells. It typically affects young males (15–35 years). The clinical hallmark is **sequential, painless, subacute visual loss** (one eye followed by the other within weeks to months). The classic triad seen on fundoscopy during the acute phase includes: 1. **Circumpapillary telangiectasia** (microangiopathy). 2. **Pseudo-edema** of the optic disc (hyperemia and swelling of the nerve fiber layer without actual leakage on FFA). 3. **Absence of pupillary light reflex impairment** (initially) and absence of pain. Perimetry typically shows a **centrocecal scotoma**, reflecting damage to the papillomacular bundle. **Why incorrect options are wrong:** * **A. Typical Optic Neuritis:** Usually presents with **painful** eye movements and a significant **Relative Afferent Pupillary Defect (RAPD)**, which is absent here. * **B. Acute Papilledema:** This is bilateral disc swelling due to increased intracranial pressure. It usually presents with transient visual obscurations and enlarged blind spots, rather than early central vision loss or telangiectasia. * **C. Toxic Optic Neuropathy:** Usually presents with **simultaneous** (not sequential) bilateral vision loss and is associated with a history of tobacco, alcohol, or drug (Ethambutol) intake. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Mitochondrial (maternal) inheritance; point mutation at **11778** (most common), 3460, or 14484. * **FFA Finding:** Unlike true papilledema, the disc in LHON **does not leak** fluorescein (hence "pseudo-edema"). * **Prognosis:** Poor; however, the 14484 mutation has the highest rate of spontaneous recovery. * **Differential:** Always consider LHON in a young male with sequential painless vision loss and a "swollen" disc that doesn't leak on FFA.

Q: A patient presents with unilateral painful ophthalmoplegia. Imaging revealed an enlargement of the cavernous sinus on the affected side. What is the likely diagnosis?

Tolosa-Hunt Syndrome. **Explanation:** **Tolosa-Hunt Syndrome (THS)** is the correct diagnosis. It is characterized by idiopathic, non-specific granulomatous inflammation of the cavernous sinus, superior orbital fissure, or orbital apex. * **Clinical Presentation:** Patients present with **painful ophthalmoplegia** (cranial nerves III, IV, and VI involvement) and dramatic responsiveness to systemic corticosteroids. * **Imaging:** MRI typically shows enlargement or "fullness" of the cavernous sinus due to inflammatory tissue, which explains the findings in this case. **Analysis of Incorrect Options:** * **Gradenigo Syndrome:** This involves a triad of suppurative otitis media, abducens nerve (CN VI) palsy, and trigeminal (CN V) pain. It is caused by **petrous apicitis**, not cavernous sinus enlargement. * **Cavernous Sinus Thrombosis (CST):** While it presents with painful ophthalmoplegia, it is usually an acute, life-threatening infectious process (often following a facial infection) presenting with high fever, proptosis, and chemosis. Imaging would show filling defects/thrombus rather than simple enlargement. * **Orbital Pseudotumor:** This is an idiopathic inflammation of the **orbit** itself. While it causes pain and restricted eye movements, the pathology is localized to the extraocular muscles or globe, not the cavernous sinus. **High-Yield Pearls for NEET-PG:** * **Diagnosis of Exclusion:** THS is diagnosed only after ruling out tumors, sarcoidosis, and infections. * **Steroid Test:** A rapid clinical improvement (within 48–72 hours) after starting high-dose steroids is a diagnostic hallmark of THS. * **Nerves Involved:** CN III is most commonly affected, followed by VI and IV. Sensory loss in the V1/V2 distribution may also occur.

Question 1

Binasal hemianopia is seen in which of the following conditions?

Accepted Answer

Bilateral lateral chiasma lesions

Answer

Optic nerve lesions

Answer

Central chiasma lesions

Answer

Optic tract lesion

Question 2

Sudden, transient, and painless loss of vision may be complained by patients with all of the following diseases except?

Accepted Answer

Papillitis

Answer

Carotid transient ischemic attacks

Answer

Papilledema

Answer

Migraine

Question 3

A 60-year-old man presents with optic disc swelling in the right eye and optic atrophy in the left eye. What is the most likely diagnosis?

Accepted Answer

Anterior ischemic optic neuropathy

Answer

Left sphenoid ridge meningioma

Answer

Leber's hereditary optic neuropathy

Answer

Left optic nerve glioma

Question 4

Bilateral retrobulbar neuritis occurs in:

Accepted Answer

Both of the above

Answer

Multiple sclerosis

Answer

Neuromyelitis optica

Answer

None of the above

Question 5

A spiral field defect is a characteristic feature of which condition?

Accepted Answer

Hysterical amblyopia

Answer

Amblyopia exanopsia

Answer

Malingering

Answer

Toxic amblyopia

Question 6

In complete 3rd Nerve palsy, which of the following are clinical features?

Accepted Answer

Superior and inferior recti affected, Dilated pupil, Ptosis, Conversion/accommodation is lost

Answer

Superior and inferior recti affected, Dilated pupil, Ptsosis

Answer

Eye deviated medially, Superior and inferior recti affected, Dilated pupil, Ptosis

Answer

Eye deviated medially, Dilated pupil, Ptosis, Conversion/accommodation is lost

Question 7

A female presented with loss of vision in both eyes. On examination, she has normal pupillary responses and a normal fundus. Her visually evoked response (VER) examination shows extinguished responses. What is the most likely diagnosis?

Accepted Answer

Cortical blindness

Answer

Hysteria

Answer

Optic neuritis

Answer

Retinal detachment

Question 8

A young man presents with blurring of vision in the right eye, followed by the left eye after 3 months. Examination reveals disc hyperemia, edema, circumpapillary telangiectasia with normal pupillary response and centrocecal scotoma on perimetry. What is the most likely cause?

Accepted Answer

Leber's hereditary optic neuropathy

Answer

Typical optic neuritis

Answer

Acute papilledema

Answer

Toxic optic neuropathy

Question 9

A patient presents with unilateral painful ophthalmoplegia. Imaging revealed an enlargement of the cavernous sinus on the affected side. What is the likely diagnosis?

Accepted Answer

Tolosa-Hunt Syndrome

Answer

Gradenigo syndrome

Answer

Cavernous sinus thrombosis

Answer

Orbital pseudotumor

Question 10

When a small target is oscillated in front of a patient with binocular vision, the patient sees the movement of the object in an elliptical orbit rather than a to-and-fro path. What is this phenomenon known as?

Accepted Answer

Pulfrich phenomenon

Answer

Oppenheim phenomenon

Answer

Uthoff phenomenon

Answer

Paroxysmal convergence spasm phenomenon

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

On this page

Practice by Chapter

Want unlimited practice?