Eyes And Neuro-ophthalmology

Question 1

What is a Pel’s crisis?

Answer 1

A tabetic ocular crisis - acute intense pain in eye and light sensitivity associated with tertiary syphilis

Question 2

What is a syphilitic ocular crisis called?

Answer 2

Pel’s crisis

Question 3

What is an Argyll-Robertson pupil?

Answer 3

Bilateral small irregular and unequal pupils that accommodate (reduce in size when looking at a near object) but do not react to light (don’t constrict in bright light)

Question 4

What is the name for bilateral small pupils that accommodate but don’t react to light? With what is this associated?

Answer 4

Argyll-Robertson pupil

Associated with syphilis

Question 5

What is near-light dissociation?

Answer 5

A feature of Argyll Robertson pupil - accommodation to near objects but don’t react to light

Question 6

Apart from AR, what is the general area of the lesion causing light near dissociation and what are 4 other differentials?

Answer 6

Midbrain - iridodilator nerve function
Diabetes mellitus
Alcoholic midbrain degeneration
Tonic phase of Holmes Adie pupil
Midbrain lesions - sarcoidosis, encephalitis, Parinaud's syndrome

Question 7

What are the two alternative names for Parinaud’s syndrome?

Answer 7

Dorsal midbrain syndrome/vertical gaze palsy

Question 8

What causes Parinaud’s syndrome?

Answer 8

Upper dorsal brainstem (midbrain) lesions - commonly pineal gland tumours
Leading to compression of the vertical gaze centre at the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF)

Question 9

What can pineal gland tumours/dorsal midbrain lesions cause and what do they disrupt to do this?

Answer 9

Parinaud’s syndrome, via disruption of the rostral interstitial nucleus of the medial longitudinal fasciculus riMLF

Question 10

What are the 6 characteristic features of Parinaud’s syndrome?

Answer 10

Upgaze paralysis (supranuclear)
Near-light dissociation
Convergence retraction nystagmus (globes retract)
Eyelid retraction 
Conjugate down gaze - setting sun sign
Bilateral papilloedema

Question 11

2 common causes of conjugate down gaze/setting sun sign?

Answer 11

Parinaud’s syndrome

Raised ICP - failed VP shunts

Question 12

What is Colliers sign?

Answer 12

Eyelid retraction associated with dorsal upper midbrain lesion e.g. Parinaud’s syndrome, Miller Fisher syndrome

Question 13

What is suggested by eyes in which you can see the sclera above the iris, which is exacerbated by attempted upgaze?

Answer 13

Collier’s sign - Parinaud’s syndrome

Question 14

3 common patient groups with Parinaud’s syndrome?

Answer 14

Pineal/midbrain tumours e.g. Pinealoma/intracranial germinomas in young patients
Young women with MS
Older patients with upper brainstem stroke

Question 15

Describe internuclear ophthalmoplegia?

Answer 15

Failure of adduction of the affected eye, with nystagmus of the unaffected eye and resultant horizontal diplopia (when looking to the non-affected side)

Question 16

Lesions of what cause INO?

Answer 16

The medial longitudinal fasciculus

Question 17

How does the MLF coordinate conjugate eye movement?

Answer 17

Connects the paramedian pontine reticular formation abducens nucleus complex of the contralateral side to the oculomotor nucleus of the ipsilateral side

Question 18

What is the classical cause of bilateral INO?

Answer 18

MS - bilateral MLF lesions

Question 19

What is a likely cause of unilateral INO in older patients?

Answer 19

Stroke affecting MLF region

Question 20

What is one and a half syndrome of the eyes?

Answer 20

Lesion affecting the paramedian pontine reticular formation or abducens nucleus on one side and the MLF on the same side (which has crossed over) causes paralysis of all conjugate horizontal eye movements other than abduction of the eye on the opposite side of the lesion

Question 21

What does painless optic neuritis suggest?

Answer 21

Less likely to be MS - consider ischaemic, compressive neuropathy

Question 22

What is the Adie tonic pupil?

Answer 22

A tonically dilated pupil that reacts slowly to light but definitively to accommodation (light-near dissociation)

Question 23

What is the name for a tonically dilated pupil that reacts slowly to light but quickly to accommodation?

Answer 23

Adie pupil

Question 24

What is the Holmes Adie syndrome?

Answer 24

Tonic dilated Adie pupil plus impaired sweating/ANS dysfunction and absent knee/ankle jerks, often seen in women

Question 25

What causes Adie syndrome?

Answer 25

Damage to the post-ganglionic fibres/ciliary ganglion of parasympathetic nervous system innervation of the eye and DRG ANS, often related to post-infection

Question 26

What causes the ANS symptoms in Holmes Adie syndrome?

Answer 26

Damage to DRG in spinal cord

Question 27

What test can be used to confirm a tonically dilated pupil?

Answer 27

Use of low dose pilocarpine, a constrictor which shouldn’t normally constrict in low dose. If it does so it suggests cholinergic denervation supersensitivity

Question 28

What does painless optic neuritis suggest?

Answer 28

Less likely to be ms - consider e.g. Ischaemic or compressive optic neuropathy

Question 29

What are cotton wool spots?

Answer 29

Micro-infarcts causing interruption of axonal transport and build up of opaque organelles

Question 30

Where do flame haemorrhages arise from?

Answer 30

Haemorrhage within nerve fascicle bundles

Question 31

Can a hemivisual field defect be due to an optic ischaemic event? Why/not?

Answer 31

No - vascular pattern to optic nerve does not allow it. Can have a lower or upper half defect but not nasal/temporal