Neuro-Opthalmology

Question 1

What are the important causes of optic disc swelling? *

Answer 1

Optic neuritis 
Papilloedema (must be bilateral) 
Malignant hypertension 
Arteritic anterior ischaemic optic neuropathy (arteritic AION) 
Non-arteritic AION

Question 2

How does optic neuritis present?

Answer 2

Retrobulbar pain especially with eye movement, associated with globe tenderness

Question 3

What would be seen on examination of optic neuritis?

Answer 3

disc may not be swollen
relative afferent pupillary defect
red desaturation
central scotoma on field testing

Question 4

How does papilloedema present?

Answer 4

symptoms include transient visual obscurations

Question 5

What is seen on examination of papilloedema?

Answer 5

splinter haemorrhages 
exudates
cotton wool spots
retinal folds near the disc 
enlarged blind spots

gradually progressive field loss - generalised constriction

eventual atrophic changes

Question 6

How does arthritic anterior ischaemic optic neuropathy (AION) present?

Answer 6

temporal headache associated with jaw claudication, weight loss, myalgia

visual loss caused by inflammatory infarction of posterior ciliary artery

ESR and CRP raised

Question 7

How should arthritic anterior ischaemic optic neuropathy (AION) be treated?

Answer 7

needs urgent treatment with high dose steroids

temporal artery biopsy should be performed within a week of starting treatment

treatment continues for at least 2 years

Question 8

What would be seen on examination of the eye with AAION?

Answer 8

optic disc margin is blurred and disc is pale

as disc is swollen

Question 9

What is non-arteritis AION?

Answer 9

Infarction of PCA as for AAION

Question 10

What are the differences between AAION and NAION?

Answer 10

In NAION

ESR is not raised
50% of patients are hypertensive
No systemic symptoms

Question 11

What is optic atrophy?

Answer 11

end stage eye disease

associated with APD

Question 12

What would be seen on eye examination of a patient with optic atrophy?

Answer 12

optic disc is pale compared to a healthy disc

Question 13

Which muscles are affected in a IIIrd nerve palsy?

Answer 13

medial rectus 
inferior rectus 
superior rectus 
inferior oblique 
levator palpeerde superioris

Question 14

How does the eye present in a third nerve palsy?

Answer 14

eye points down and out
ptosis
dilated pupil
no afferent pupillary defect

Question 15

Which muscle is affected in a IVth nerve palsy?

Answer 15

superior oblique affected

Question 16

How does the eye present in a fourth nerve palsy?

Answer 16

Eye is unable to look down and in on affected side

vertical diplopia most marked on looking down and in

bilateral cases may be seen in head injury

Question 17

Which muscle is affected in a VIth nerve palsy?

Answer 17

abducens palsy

Question 18

how does the eye present in a 4th nerve palsy?

Answer 18

inability to abduct

eye may drift medially on affected side due to pull of medial rectus

Question 19

What should you do a suspected VIIth nerve palsy?

Answer 19

May cause exposure hence

test corneal sensation
test bells phenomena

Question 20

Describe the pupil relax pathways - light reflex?

LOOK UP PICS

Answer 20

RCG –> PTN –> EWN –> Inf Div III

RCG –> PTN –> EWN –> Inf Div III

Join between PTN of top and EWN of bottom one

Question 21

Describe the pupil reflex pathways - near reflex ?

Answer 21

Pre striate cortex area 19

• -> EWN –> Inf Div III
• -> EWN –> Inf Div III

Question 22

Which test is used to look for a RAPD (relative afferent pupillary defect)?

Answer 22

swinging flashlight test

Question 23

What happens in the swinging light test in a RAPD?

Answer 23

Mild RAPD: affected pupil shows a weak initial constriction followed by a dilation to a greater size

Moderate RAPD: affected pupil shows a stable or unchanged level of constriction followed by dilation to a greater size

Severe RAPD: affected pupil shows an immediate dilation to a greater size

If both eyes were dysfunction no ‘relative’ defect would be seen

Question 24

What conditions lead to a RAPD?

Answer 24

Optic nerve disorders - for example: glaucoma, orbital disease, optic neuritis

Retinal causes of RAPD - for example: retinal detachment, severe macular degeneration, intraocular tumour

Question 25

What is the difference between a APD/RAPD?

Answer 25

APD - no direct or consensual response

RAPD - reduced light and consensual response, pupil dilates on the swinging light test

Question 26

What is anisocoria?

Answer 26

unequal pupil sizes

Question 27

What is an efferent pupillary defect?

Answer 27

III nerve or pupillary muscle affected

Loss of consensual and direct pupillary reflex in affected eye

Consensual and direct pupillary reflex in unaffected eye

Question 28

What is Horner’s syndrome?

Answer 28

lesions of the sympathetic pathway

Question 29

Describe the pupil in Horner’s syndrome?

Answer 29

affected pupil is smaller than normal

pupil inequality is more pronounced in the dark

patient may have neck scars, partial ptosis and the eye may appear to be sunken in (apparent enopthalmos)

Question 30

What is Adie’s syndrome and how does it present?

Answer 30

patient is often young and has an efferent pupillary defect on direct and consensual testing with sluggish responses

pupil constriction on convergence is often slow but miosis will eventually occur

patient may demonstrate abnormal tendon reflexes

Question 31

What are Argyll-Robertson pupils?

Answer 31

may be blind from congenital syphilis

pupils are often small and irregular with sluggish light responses and light near dissociation

Question 32

How would a patient with traumatic mydriasis present?

Answer 32

dilated pupil
facial scars
signs of pupil rupture