Neuro-Ophthalmology 2

Question 0

Approach to a patient with anisocoria – tests and Interpretation?

Answer 0

Turn off lights – dilation lag in small pupil means sympathetic defect or Horner’s syndrome

Question 1

Physiologic anisocoria – how common? Effect of different illuminations on physiologic anisocoria?

Answer 1

25% prevalence

Amount of anisocoria does not change with different illumination

Question 2

Horner’s syndrome characterized by?

Answer 2

#Unilateral meiosis
#Ptosis
#Ipsilateral facial anhydrosis (impaired sympathetic innervation)

Question 3

In every type of Horner’s syndrome can use this test?

If negative?

Answer 3

Cocaine test (negative if Cocaine eyedrops fail to dilate abnormal pupil)

Hydroxyamphetamine eyedrops to distinguish between preganglionic and postganglionic Horner’s syndrome (postganglionic Horner’s syndrome fails to dilate)

Question 4

Types of Horner’s syndrome and examples?

Answer 4

Central/first order Horner’s (hypothalamic infarcts, tumor, stroke, brainstem ischemia/hemorrhage)

Question 5

Patient presents with abnormal pupil size – other symptoms that would suggest problem is in midbrain?

Answer 5

#Hemiparesis
#Nystagmus
#Tremor
#Loss of consciousness

Question 6

Third nerve palsy characterized by?

Answer 6

#Ptosis
#Dilated pupil
#Ophthalmoplegia

Question 7

Compression of the outer part of the third nerve causes? Does not affect?

Answer 7

Pupil dilation without compromised eye movement

Outer part of third nerve contains parasympathetic fibers

Question 8

Vascular problems causing third nerve ischemia will cause? Will not affect?

Answer 8

Palsy of ocular muscles but no change in reactivity of pupil

Question 9

Adie’s pupil? Results from?

Symptoms?

Answer 9

Tonic pupil the results from interruption of the parasympathetic supply from the ciliary ganglion

#Anisocoria
#Photophobia
#Blurred near vision (accommodation paresis)

Question 10

Patient presents with dilated pupil, poor light reaction and light-near dissociation – suspected diagnosis? Confirm with?

Answer 10

Tonic (Adie’s) pupil

Super sensitivity of the pupil to pilocarpine (more contraction in the affected people than in the normal people)

Question 11

Patient presents with small regular pupils with impaired light reaction but intact near response (light-near dissociation) – suspected diagnosis?

Answer 11

Syphilis - Argyll Robertson pupil

Question 12

Light-near dissociation?

Answer 12

Pupil does not react to light but does accommodate

Implies defect in light response
#Optic neuropathy
#Adie's pupil
#Dorsal midbrain lesion
#Severe bilateral vision loss

Question 13

Etiology of papilledema? Clinical symptoms depend on? Examples?

Answer 13

Blockage of axoplasmic transport in the optic nerve

Underlying cause

#Demyelinating optic neuritis – pain with eye movements
#anterior ischemic optic neuropathy – sudden visual loss
#Space occupying lesions – morning headache

Question 14

Most common symptom of optic disc swelling? Usually precipitated by?

Answer 14

Transient visual obscurations (dimming/”blacking out” of vision for a few seconds)

Changes in posture

Question 15

Foster-Kennedy syndrome?

Answer 15

Space occupying lesion in frontal lobe causes 
#ipsilaterally optic disc atrophy 
#contralateral papilledema from increased ICP

Question 16

Pseudotumor cerebri?

Answer 16

Idiopathic intracranial hypertension

Question 17

Patient presents with drusen – also known as? Etiology? Clinical manifestation? Fundoscopy will show? Imaging?

Answer 17

Enlarged blind spot with visual acuity

Pseudopapilledema; Calcified hyaline bodies

Glistening hyaline bodies and Venus pulsation

CT/orbital ultrasound for calcified bodies

Question 18

Optic neuritis usually indicates? Also may indicate?

Answer 18

Demyelination (MS, lupus, adrenoleukodystrophy, sarcoidosis)

#Viral meningitis
#Behcet's
#Whipple
#Crohn's

Question 19

Clinical manifestations of optic neuritis?

Answer 19

Classic – central scotoma

#Painful visual loss
#Uhthoff's phenomenon – worsening vision during exercise or hot baths
#Retro orbital pain
#Loss of color vision
#marcus gun pupil

Question 20

Patient presents with loss of color vision and worsening vision during exercise – suspected diagnosis? Confirm with? Indicated therapy?

Answer 20

Optic neuritis

#MRI for demyelination
#LP

IV methylprednisolone