Neuro-Ophthalmology Practice Questions

Q: The given fundus examination reveals presence of:

Papilledema. ***Papilledema*** - The image shows a **swollen optic disc** with blurred margins, loss of the optic cup, and retinal vessel engorgement, which are characteristic signs of papilledema. - **Papilledema** is caused by increased **intracranial pressure** transmitted to the optic nerve head, leading to axoplasmic flow stasis and optic disc edema. *Glaucoma* - **Glaucoma** typically presents with **optic disc cupping** and thinning of the neuroretinal rim due to loss of ganglion cell axons, which is opposite to the features seen in the image. - The optic disc in glaucoma often appears pale and excavated, not swollen and hyperemic as depicted. *Retinitis pigmentosa* - **Retinitis pigmentosa** is characterized by **nyctalopia**, peripheral visual field loss, and funduscopic findings like **bone-spicule pigment deposits**, attenuated retinal vessels, and waxy pallor of the optic disc. - None of these typical features of retinitis pigmentosa are visible in the provided image. *Temporal crescent* - A **temporal crescent** refers to a myopic conus or scleral crescent, which is an area of exposed sclera that appears as a white or yellowish crescent at the temporal border of the optic disc, often seen in high myopia. - The image does not show an area of exposed sclera but rather an elevated and congested optic disc.

Q: An 8-year-old child presents with gradual reduction in vision in the right eye. Family history of similar presentation was elicited on the maternal side. On examination, on right side direct light reflex is absent and consensual light reflex is present. Fundus examination was performed. What is the diagnosis?

Optic atrophy. ***Optic atrophy*** - The clinical finding of **gradual reduction in vision**, **absent direct light reflex** (indicating an afferent pupillary defect), and **present consensual light reflex** in the affected eye confirms optic nerve pathology. - The fundus image shows **optic disc pallor**, indicating loss of retinal ganglion cell axons, which is characteristic of optic atrophy. - The **positive family history on the maternal side** in an 8-year-old child strongly suggests **hereditary optic atrophy** (such as Leber's Hereditary Optic Neuropathy or Dominant Optic Atrophy), making this the most likely diagnosis. *ICSOL* - **Intracranial space-occupying lesions** can cause compressive optic neuropathy and secondary optic atrophy, but typically present with other neurological signs such as headache, papilledema, or focal neurological deficits. - While possible, the strong family history and isolated unilateral presentation in a child make hereditary optic atrophy more likely than an acquired ICSOL. *Devic's disease* - **Devic's disease** (Neuromyelitis Optica Spectrum Disorder) involves optic neuritis and transverse myelitis, typically presenting with acute, painful, often bilateral vision loss along with spinal cord symptoms. - The gradual, unilateral vision loss with established optic disc pallor suggests chronic nerve damage rather than the acute inflammatory process seen in Devic's disease. - Family history is not a typical feature of NMO. *Iritis* - **Iritis** (anterior uveitis) is an inflammatory condition of the iris characterized by eye pain, redness, photophobia, and decreased vision due to inflammation. - Examination would reveal inflammatory cells in the anterior chamber, circumcorneal congestion, and possibly posterior synechiae—not optic disc pallor. - Iritis does not cause afferent pupillary defects or optic nerve damage as the primary pathology.

Q: The following fundus finding is seen in:

Papilledema. ***Papilledema*** - The image shows a **swollen optic disc** with blurred margins, a classic sign of papilledema, which is caused by increased **intracranial pressure**. - Visible **venous engorgement** and **hemorrhages** near the disc further support the diagnosis of papilledema. *Myopia* - Myopia (nearsightedness) is characterized by a **longer eyeball**, which can sometimes cause a tempora-crescent or peripapillary atrophy, but not a swollen, blurred disc. - The optic nerve head in myopia is usually normal or may show some **conus** at the temporal margin without disc swelling. *Hypermetropia* - Hypermetropia (farsightedness) is due to a **shorter eyeball** and may present with a small, crowded optic disc, a condition sometimes confused with mild papilledema, but usually without the pronounced blurring and hemorrhages. - The vessels typically appear normal, and there is no evidence of increased intracranial pressure. *Diabetic retinopathy* - Diabetic retinopathy is characterized by **microaneurysms**, **hemorrhages**, **exudates**, and sometimes **neovascularization**, none of which are the primary finding in this image. - While it can cause retinal vascular changes, it does not typically present with bilateral optic disc swelling like papilledema.

Q: The following visual loss is seen due to lesion in:

Optic chiasma. ***Optic chiasma*** - The image shows **bitemporal hemianopsia**, characterized by loss of vision in the **temporal (outer) halves of both visual fields**. - This specific visual field defect occurs due to damage to the **crossing nasal fibers** within the optic chiasma, which carry information from the temporal visual fields. *Optic tract* - A lesion in the optic tract would cause a **homonymous hemianopsia**, meaning loss of vision in the **same half of the visual field** for both eyes (e.g., right homonymous hemianopsia). - This is because the optic tract contains fibers from the contralateral nasal retina and ipsilateral temporal retina. *Optic radiation* - Damage to the optic radiation typically results in **homonymous quadrantanopia** or **homonymous hemianopsia**, depending on the extent and location of the lesion. - For instance, a lesion in the temporal lobe (Meyer's loop) affects the superior visual field and causes **superior homonymous quadrantanopia**. *Posterior calcarine fissure* - A lesion in the posterior calcarine fissure (primary visual cortex) would cause a **contralateral homonymous hemianopsia with macular sparing**. - Macular sparing often occurs because the macula's representation is usually spared due to its dual blood supply or extensive representation.

Q: A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

6th nerve palsy. ***6th nerve palsy*** - The image shows the **right eye** is unable to **abduct** (move outwards) when looking to the right, and is **adducted** (turned inwards) when looking straight ahead, which is characteristic of a **sixth cranial nerve (abducens) palsy**. - The abducens nerve innervates the **lateral rectus muscle**, which is responsible for abduction of the eye. Its paralysis causes the affected eye to deviate medially due to the unopposed action of the medial rectus muscle. *2nd nerve palsy* - **Second nerve (optic nerve) palsy** would primarily present with **vision loss** or field defects, not with abnormal eye movements. - The optic nerve transmits visual information from the eye to the brain and does not control ocular motility. *3rd nerve palsy* - **Third nerve (oculomotor) palsy** typically presents with **ptosis**, **dilated pupil**, and the eye positioned **down and out**. - This is because the oculomotor nerve innervates most extraocular muscles (medial, superior, inferior rectus, inferior oblique) and the levator palpebrae superioris, as well as pupillary constrictors. *4th nerve palsy* - **Fourth nerve (trochlear) palsy** affects the **superior oblique muscle**, leading to **vertical diplopia** and the eye being unable to move down and in. - Patients often compensate by **tilting their head** to the opposite shoulder.

Q: What is the diagnosis?

Third nerve palsy. ***Third nerve palsy*** - The image shows **ptosis** (drooping of the eyelid) and **pupil dilation** with the eye deviated **down and out**, which are classic signs of a complete third nerve palsy. - The **oculomotor nerve (CN III)** innervates most extraocular muscles (**superior, medial, inferior recti, and inferior oblique**), the **levator palpebrae superioris**, and the **parasympathetic fibers to the pupillary constrictor muscle**. *Sixth nerve palsy* - A sixth nerve palsy (**abducens nerve**) would cause an inability to **abduct the eye** (move it outwards) leading to an **esotropia** (eye turned inward at rest) and **horizontal diplopia**, which is not depicted. - Symptoms primarily affect the **lateral rectus muscle**. *Myasthenia gravis* - Myasthenia gravis can cause **ptosis** and **diplopia**, but typically presents with **variable and fluctuating weakness** that worsens with fatigue. - It does not usually cause the fixed, specific pattern of strabismus and pupillary involvement seen in a severe third nerve palsy. *Tolosa-Hunt syndrome* - Tolosa-Hunt syndrome is a **painful ophthalmoplegia** caused by **non-specific inflammation** in the cavernous sinus or orbital apex. - While it can affect cranial nerves III, IV, V1, and VI, leading to **ophthalmoplegia** and **ptosis**, the defining feature is often **severe orbital pain**, which cannot be assessed from the image alone, and the specific constellation of symptoms in the image points more directly to a third nerve lesion rather than an inflammatory syndrome.

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

Question 1

The given fundus examination reveals presence of:

Accepted Answer

Papilledema

Answer

Glaucoma

Answer

Retinitis pigmentosa

Answer

Temporal crescent

Question 2

An 8-year-old child presents with gradual reduction in vision in the right eye. Family history of similar presentation was elicited on the maternal side. On examination, on right side direct light reflex is absent and consensual light reflex is present. Fundus examination was performed. What is the diagnosis?

Accepted Answer

Optic atrophy

Answer

ICSOL

Answer

Devic's disease

Answer

Iritis

Question 3

The following fundus finding is seen in:

Accepted Answer

Papilledema

Answer

Myopia

Answer

Hypermetropia

Answer

Diabetic retinopathy

Question 4

The pupils shown below are miotic and irregular in shape. They are nonreactive to light but react to accommodation. They also do not dilate with atropine. All are causes of these pupils except:

Accepted Answer

Multiple sclerosis

Answer

Diabetes mellitus

Answer

Pinealoma

Answer

Iridocyclitis

Question 5

The following visual loss is seen due to lesion in:

Accepted Answer

Optic chiasma

Answer

Optic tract

Answer

Optic radiation

Answer

Posterior calcarine fissure

Question 6

A patient presents with the eye movement abnormalities shown in the image below. What is the diagnosis?

Accepted Answer

Internuclear ophthalmoplegia

Answer

Left 3rd nerve palsy

Answer

Horizontal gaze palsy

Answer

Duane retraction syndrome

Question 7

A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

Accepted Answer

6th nerve palsy

Answer

2nd nerve palsy

Answer

3rd nerve palsy

Answer

4th nerve palsy

Question 8

What is the diagnosis?

Accepted Answer

Third nerve palsy

Answer

Sixth nerve palsy

Answer

Myasthenia gravis

Answer

Tolosa-Hunt syndrome

Question 9

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 10

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

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

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