Neuro-Ophthalmology Practice Questions

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.

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**.

Question 1

The following fundus finding is seen in:

Accepted Answer

ICSOL

Answer

Retinitis pigmentosa

Answer

Multiple sclerosis

Answer

Hysterical blindness

Question 2

Identify the visual field defect shown in the image.

Accepted Answer

Bitemporal hemianopia

Answer

Binasal hemianopia

Answer

Homonymous hemianopia

Answer

Altitudinal defect

Question 3

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 4

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 5

Most common optic nerve tumor in children causing blindness:

Accepted Answer

Glioma

Answer

Astrocytoma

Answer

Craniopharyngioma

Answer

Meningioma

Question 6

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 7

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

Accepted Answer

Hyperchromatic iris

Answer

Anhidrosis

Answer

Enophthalmos

Answer

Miosis

Question 8

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 9

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 10

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

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

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