Neuro-Ophthalmology Practice Questions

Q: Sea-saw nystagmus is seen in which of the following conditions?

Craniopharyngioma. **Explanation:** **See-saw nystagmus** is a unique clinical sign characterized by a rhythmic cycle where one eye elevates and intorts while the other eye simultaneously depresses and extorts. This "pendular" movement is most commonly associated with **parasellar lesions** that compress the optic chiasm and/or involve the diencephalon (midbrain-diencephalic junction). **1. Why Craniopharyngioma is correct:** Craniopharyngiomas are the most common parasellar tumors in children and young adults. Because they occupy the suprasellar space, they frequently compress the optic chiasm and involve the third ventricle/diencephalon. This disruption of the visual pathways and the interstitial nucleus of Cajal (which coordinates vertical and torsional eye movements) results in the classic see-saw nystagmus. It is often accompanied by a bitemporal hemianopia. **2. Why other options are incorrect:** * **Anterior Longitudinal Fasciculus:** This is not a recognized anatomical structure associated with nystagmus. The *Medial Longitudinal Fasciculus (MLF)* is the relevant structure for eye movements, but its lesion causes Internuclear Ophthalmoplegia (INO), not see-saw nystagmus. * **Medullary lesion:** Lesions in the medulla (e.g., Wallenberg syndrome) typically cause **Downbeat nystagmus** or horizontal nystagmus, but not see-saw. * **Guillain-Barré Syndrome:** This is a peripheral polyneuropathy. While the Miller Fisher variant can cause ophthalmoplegia (paralysis of eye muscles), it does not typically present with nystagmus. **High-Yield Clinical Pearls for NEET-PG:** * **See-saw Nystagmus:** Think **Craniopharyngioma** or **Chiasmal lesions**. * **Downbeat Nystagmus:** Think **Arnold-Chiari Malformation** (Foramen magnum lesions). * **Upbeat Nystagmus:** Think **Medullary** or **Cerebellar vermis** lesions. * **Bruns Nystagmus:** Seen in **Cerebellopontine (CP) angle tumors** (e.g., Vestibular Schwannoma).

Q: Which of the following is FALSE regarding Horner's syndrome?

Horner's pupil dilates with topical cocaine. **Explanation:** Horner’s syndrome results from a lesion in the **oculosympathetic pathway**. To identify the false statement, we must understand the pharmacological basis of the diagnostic tests. **Why Option C is the Correct (False) Statement:** The **Cocaine Test** is the traditional gold standard for diagnosing Horner’s syndrome. Cocaine acts by blocking the reuptake of norepinephrine at the synaptic cleft. In a normal eye, this causes pupillary dilation. However, in Horner’s syndrome (regardless of the lesion site), there is a lack of norepinephrine release from the nerve endings. Therefore, **the Horner’s pupil will NOT dilate** (or dilates poorly) with topical cocaine, while the normal pupil dilates well, increasing the degree of anisocoria. **Analysis of Other Options:** * **Option A:** True. Horner’s is defined by a triad (ptosis, miosis, anhidrosis) caused by a disruption in the three-neuron sympathetic chain. * **Option B:** True. The **ciliospinal reflex** (pupillary dilation in response to painful stimuli on the neck) is mediated by the sympathetic pathway. Its loss is a clinical sign of Horner’s. * **Option D:** True. **Dilation lag** (the pupil redilates slower than normal when lights are dimmed) is a classic clinical sign. The cocaine test confirms the diagnosis. **NEET-PG High-Yield Pearls:** 1. **Apraclonidine Test:** Now more commonly used than cocaine. It causes **reversal of anisocoria** (the Horner’s pupil dilates due to denervation supersensitivity of alpha-1 receptors, while the normal pupil remains unchanged). 2. **Hydroxyamphetamine Test:** Used for **localization**. It dilates 1st and 2nd-order lesions but **fails to dilate 3rd-order (post-ganglionic) lesions**. 3. **Clinical Triad:** Partial ptosis (Müller’s muscle palsy), Miosis, and Anhidrosis. Apparent enophthalmos is also noted.

Q: Amaurosis fugax does not occur in which of the following conditions?

Papillitis. **Explanation:** **Amaurosis Fugax** refers to sudden, transient, painless monocular vision loss (typically lasting seconds to minutes) followed by complete recovery. It is essentially a "TIA of the eye," usually caused by temporary vascular compromise. **Why Papillitis is the correct answer:** Papillitis is a form of **Optic Neuritis** (inflammation of the optic nerve head). Vision loss in optic neuritis is typically **subacute, progressive, and persistent** (lasting days to weeks), often associated with pain on ocular movement. It does not present with the transient, "flickering" vision loss characteristic of amaurosis fugax. **Analysis of Incorrect Options:** * **Migraine:** Retinal migraines cause transient vasospasm of the retinal or ciliary arteries, leading to classic amaurosis fugax. * **Giant Cell Arteritis (GCA):** This is a critical cause. Ischemia of the posterior ciliary arteries can cause transient visual obscurations (TVOs) or amaurosis fugax, often serving as a warning sign before permanent vision loss from Anterior Ischemic Optic Neuropathy (AION). * **Venous Stasis Retinopathy:** Occurring in the context of Carotid Artery Occlusive Disease, the reduced perfusion pressure leads to transient blurring or "white-outs" of vision, especially when moving from dim to bright light. **Clinical Pearls for NEET-PG:** * **Most common cause:** Emboli from the **ipsilateral carotid artery** (Hollenhorst plaques). * **Transient Visual Obscurations (TVOs):** Brief episodes of vision loss (1-10 seconds) triggered by postural changes; these are classic for **Papilledema** (raised ICP), not Papillitis. * **Uhthoff’s Phenomenon:** Transient worsening of vision in Optic Neuritis due to increased body temperature (exercise/hot showers). This is distinct from amaurosis fugax.

Q: Fundoscopic features of papilledema include all the following except?

Deep physiological cup. **Explanation:** **Papilledema** refers specifically to optic disc swelling secondary to increased intracranial pressure (ICP). The fundamental pathophysiology involves the transmission of high CSF pressure through the subarachnoid space surrounding the optic nerve, which causes stasis of axoplasmic flow and vascular congestion. **Why "Deep physiological cup" is the correct answer:** In papilledema, the swelling of the optic nerve fibers and the accumulation of extracellular fluid cause the optic disc to protrude anteriorly into the vitreous. This process **obliterates (fills in)** the physiological cup. A "deep physiological cup" is actually a characteristic feature of **Glaucoma** (cupping), making it the opposite of what is seen in papilledema. **Analysis of incorrect options:** * **A. Ill-defined disc margin:** This is the earliest sign of papilledema. Edema starts at the nasal margin and spreads circumferentially, blurring the edges. * **C. Absent venous pulsation:** Spontaneous Venous Pulsation (SVP) is lost when ICP exceeds 200 mmH₂O. While 20% of the normal population lacks SVP, its *disappearance* in a patient who previously had it is a sensitive indicator of rising ICP. * **D. Bending of blood vessels:** As the disc becomes elevated (dome-shaped), the retinal vessels must climb over the swollen edges, causing them to "bend" or "curve" sharply at the disc margin. **High-Yield Clinical Pearls for NEET-PG:** * **Paton’s Lines:** Circumferential retinal folds seen on the temporal side of the swollen disc. * **Foster Kennedy Syndrome:** Anosmia, ipsilateral optic atrophy (due to direct tumor compression), and contralateral papilledema (due to raised ICP). * **Early vs. Late:** In early papilledema, visual acuity is usually **preserved**, whereas in optic neuritis (inflammatory swelling), vision loss is sudden and severe. * **Modified Frisén Scale:** Used for clinical grading of papilledema severity.

Q: All of the following drugs are used for the management of postherpetic neuralgia except?

Cycloplegics. **Explanation:** Postherpetic Neuralgia (PHN) is a chronic neuropathic pain syndrome persisting for more than 90 days after the onset of a Herpes Zoster rash. The management focuses on stabilizing overactive pain signaling in the peripheral and central nervous systems. **Why Cycloplegics are the Correct Answer:** Cycloplegics (e.g., Atropine, Homatropine) are used in the **acute phase** of Herpes Zoster Ophthalmicus (HZO) to treat associated anterior uveitis and ciliary spasm. They have no role in managing **Postherpetic Neuralgia**, which is a chronic neurological pain condition rather than an active inflammatory ocular condition. **Analysis of Incorrect Options:** * **Nortriptyline:** Tricyclic Antidepressants (TCAs) like Nortriptyline and Amitriptyline are first-line systemic agents for PHN. They work by inhibiting the reuptake of serotonin and norepinephrine, modulating pain pathways. * **Capsaicin Cream:** This is a topical alkaloid derived from chili peppers. It works by depleting **Substance P** from peripheral sensory neurons, thereby desensitizing the area to pain. * **Gabapentin:** An anticonvulsant that binds to the $\alpha_2\delta$ subunit of voltage-gated calcium channels. It is a mainstay of treatment for neuropathic pain. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Sign:** Vesicles on the tip of the nose (involvement of the nasociliary nerve) indicate a high risk of ocular involvement in HZO. * **First-line for PHN:** Gabapentin, Pregabalin, or TCAs (Nortriptyline is often preferred over Amitriptyline in elderly patients due to fewer anticholinergic side effects). * **Acute HZO Treatment:** Oral Acyclovir (800 mg 5 times daily for 7–10 days) started within 72 hours of rash onset reduces the risk of PHN.

Question 1

Sea-saw nystagmus is seen in which of the following conditions?

Accepted Answer

Craniopharyngioma

Answer

Lesion of the anterior longitudinal fasciculus

Answer

Medullary lesion

Answer

Guillain-Barré Syndrome

Question 2

Which of the following is FALSE regarding Horner's syndrome?

Accepted Answer

Horner's pupil dilates with topical cocaine

Answer

Lack of sympathetic innervation

Answer

Loss of ciliospinal reflex

Answer

Confirmatory tests include dilation lag and cocaine test

Question 3

Pseudopapilitis is seen in which of the following conditions?

Accepted Answer

Hypermetropia

Answer

Myopia

Answer

Squint

Answer

Presbyopia

Question 4

A patient's pupil fails to dilate when cocaine is administered. Which of the following conditions is the most likely cause?

Accepted Answer

Peripheral sympathetic paralysis

Answer

Central sympathetic paralysis

Answer

Central parasympathetic paralysis

Answer

Peripheral parasympathetic paralysis

Question 5

Amaurosis fugax does not occur in which of the following conditions?

Accepted Answer

Papillitis

Answer

Migraine

Answer

Giant cell arteritis

Answer

Venous stasis retinopathy

Question 6

Fundoscopic features of papilledema include all the following except?

Accepted Answer

Deep physiological cup

Answer

Ill-defined disc margin

Answer

Absent venous pulsation

Answer

Bending of blood vessels

Question 7

A patient with rheumatoid arthritis, on long-term NSAID treatment (diclofenac) for joint pain, presents with reduced visual acuity and loss of colour vision. What is the likely diagnosis?

Accepted Answer

Optic neuritis

Answer

Open angle glaucoma

Answer

Angle closure glaucoma

Answer

Senile cataract

Question 8

All of the following drugs are used for the management of postherpetic neuralgia except?

Accepted Answer

Cycloplegics

Answer

Nortriptyline

Answer

Capsaicin cream

Answer

Gabapentin

Question 9

Which of the following is FALSE regarding optic atrophy?

Accepted Answer

Pallor of the disc is due to the degeneration of nerve fibres.

Answer

The disc is chalky white in primary optic atrophy.

Answer

Pallor of the disc cannot be correlated with the amount of visual loss.

Answer

All of the above are false.

Question 10

Aberrant regeneration does not occur after injury to the oculomotor nerve with which one of the following conditions?

Accepted Answer

Ischemia secondary to diabetes

Answer

Trauma

Answer

Tumor compression

Answer

Aneurysm

Neuro-Ophthalmology — MCQs

Neuro-Ophthalmology — MCQs

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