Neuro-ophthalmology

Question 1

Physiologic anisocoria

Answer 1

in 25%, responds to light and accommodation

Question 2

smaller pupil is problem (anisocoria greater in dark)

Answer 2

Horner’s syndrome: miosis, ptosis, sometimes ipsilateral facial anhidrosis.

Question 3

Horner’s syndrome

Answer 3

impaired sympathetics
does not dilate to cocaine eyedrops
then test hydroxyamphetamine droms: if postganglionic HIS, will also fail to dilate.

Question 4

Causes of central horner’s (first order)

Answer 4

hypothalamic infarcts, tumor, mesencephalic stroke, brainstem: ischemia (wallenberg syndrome), tumor, hemorrhage

Question 5

Wallenberg syndrome

Answer 5

aka Lateral Medullary Syndrome
PICA or vertebral stroke
Ipsilateral V (loss of sensation in ipsilateral face)
Spinalthalamic tract (contralateral body numbness– pain and temp)

Vestibular nuclei, cerebellar ataxia, ipsilateral IX, X palatal hemiparesis.
Ipsilateral horners from descending sympathetics

Question 6

Second order Horners, preganglionic

Answer 6

Cervicothoracic cord/spinal root, cervical spondylosis, pullmonary apical tumor: pancoast tumor

Question 7

Third-order Horner’s, postganglionic

Answer 7

superior cervical ganglion, internal carotid a., base of skull tumor, middle ear problems, cavernous sinus: tumor, aneurysm

Question 8

Third n. palsy

Answer 8

ptosis, dilated pupil (mydriatic), ophthalmoplegia. Because parasympathetics run in outer part of 3rd n. and motor fibers are internal, compression of n produces dilated pupil wo ophthalmoplegia. Vascular problems will produce pupil sparing 3rd n lesion.

Question 9

Adie’s tonic pupil

Answer 9

interruption of parasympathetic supply from ciliary ganglion (postganglionic fibers): anisocoria, dilated pupil, photophobia, blurred near vision (accommodation paresis sometimes), light near dissociation.
Confirmation by supersensitivity to pilocarpine (produces more contraction in affected pupil than normal pupil).

Question 10

Argyll Robertson pupil

Answer 10

syphilis

light near dissociation. pupils dilate poorly to mydriatic agents.

Question 11

Most common cause of ODS (optic disc swelling)

Answer 11

optic neuritis, AION (anterior ischemic optic neuropathy), orbital compression lesions.

Question 12

Foster-Kennedy syndrome

Answer 12

ipsilateral optic disc atrophy due to compression by space occupying lesion due to ICP.

Question 13

Parks 3 step test

Answer 13

1. Hypertropia in primary gaze
2. Increased hypertropia in contralateral gaze
3. Increased hypertropia in ipsilateral head tilt.

Question 14

One and a half syndrome

Answer 14

Lesion in MLF, 6 nucleus, PPRF

Only preserved horizontal movement is contralateral abduction.

Question 15

What controls vertical coordinated eye movements?

Answer 15

Rostral interstitial MLF

Question 16

What controls vertical pursuits?

Answer 16

Interstitial nucleus of Cajal

Question 17

Visual field abnormality for papilledema?

Answer 17

Enlarged blind spot

Question 18

Central scotoma, common causes

Answer 18

Optic neuritis or ischemic optic neuropathy

Question 19

Causes of optic neuritis and AION: look up

Answer 19

Look up

Question 20

Most common cause of 6n palsy

Answer 20

Ischemia. Diabetes

Question 21

Pituitary apoplexy, sheehan’s syndrome

Answer 21

Hemorrhagic infarction of pituitary peripartum

Adrenal insufficiency, bitemporal hemianopsia

Question 22

INO major causes

Answer 22

Older person: para median pontine perforating vessel stroke

Younger person: demyelination

Question 23

Pain on movement of eye with central scotoma. Normal fundus with poor vision!

Answer 23

Optic neuritis

Question 24

Optic neuritis

Answer 24

Pain on movement of eye with central scotoma. Normal fundus with poor vision. APD on affected side.

Question 25

Giant cell arteritis

Answer 25

Associated with poly myalgia rheumatica. Risk for central retinal artery occlusion. ESR elevation. Dx with temporal artery biopsy.
Fundus shows mild disc swelling and peri papillary hemorrhage. No emboli are seen in retinal arteries.

Question 26

Decreased vision, headache, ipsilateral APD, 77 yo woman

Answer 26

Central retinal artery occlusion and giant cell arteritis.

Question 27

Basilar migraine

Answer 27

Dizziness, slurred speech, double vision in child! Headache and vomiting.

Question 28

Post comm aneurysm

Answer 28

Painful, pupil-involving 3n palsy.
Do CT, LP, angiography.
Consider vassos plasm if clipping doesn’t help and tx with nimodipine.

Question 29

INO Intranuclear ophthalmoplegia

Answer 29

Problems in ipsilateral eye adduction on contralateral gaze.
Nystagmus in contralateral eye.

Question 30

Causes of bilateral INOs

Answer 30

Weirnicke’s encephalopathy

Botulism, MG, Brainstem strokes, demyelination

Question 31

Increased ICP visual field

Answer 31

papilledma, Transient visual obscurations, enlargement of blindspot.

Question 32

Ischemic optic neuropathies

Answer 32

Most frequent acute optic neuropathy in >50yo.
Anterior ION and Posterior ION
Painless loss of vision in one eye (often altitudinal), with swollen optic disc.
Temporal Arteritis can cause optic neuropathy. Check ESR. Give Steroids.

PION is rare: after spinal surgery

Question 33

Cherry red spot

Answer 33

Central Artery Occlusion. Painless loss of vision with acute onset.

Question 34

Giant cell arteritis

Answer 34

Polymyalgia Rheumatica
Central Artery Occlusion
Headache
Pain on jaw chewing

Question 35

Drugs that cause optic neuropathy

Answer 35

Drugs: amiodarone, interferon alpha, nasal decongestants, PDE-I