Ophthalmology

Question 1

A patient presents with a central scotoma in the
left eye and a superior temporal visual defect in
the right eye. Where is the patient’s lesion?
A. In the left inferior optic radiations
B. In the right occipital pole
C. In the orbital portion of the left optic nerve
D. At the junction of the left optic nerve and
chiasm
E. In the optic chiasm

Answer 1

D. At the junction of the left optic nerve and
chiasm

Question 2

A 10-month-old girl presents to clinic after her
parents noticed that her eyes do not follow a moving object when her head is held in place. She is
diagnosed with congenital oculomotor apraxia.
What mechanism does she utilize to track objects?
A. Optokinetic reflex
B. Preserved convergence ability
C. Vestibuloocular reflex
D. Tonic labyrinthine reflex
E. Ability to turn head

Answer 2

E. Ability to turn head

Question 3

A man presents with a ptosis of the right eye,
anisocoria with the right pupil being smaller than
the left, and a history of the right upper half of his
face no longer sweating. Intraocular cocaine administration bilaterally dilates only the left eye, and
Paredrine (amphetamine) administration has no
effect on the right pupil. Where is the lesion causing the Horner syndrome?
A. Brainstem
B. Cervical spinal cord
C. Sympathetic chain proximal to the superior
cervical ganglion
D. Sympathetic chain distal to the superior cervical ganglion but proximal to the off-take of the
vasomotor fibers
E. Sympathetic chain distal to the superior cervical ganglion and distal to the off-take of the
vasomotor fibers

Answer 3

D. Sympathetic chain distal to the superior cervical ganglion but proximal to the off-take of the
vasomotor fibers

Question 4

A conjugate horizontal gaze palsy combined with
an internuclear ophthalmoplegia (one-and-a-half
syndrome) can be caused by a lesion involving the:
A. Contralateral abducens nerve and the ipsilateral medial longitudinal fasciculus
B. Bilateral paramedian pontine reticular
formations
C. Ipsilateral paramedian pontine reticular formation and the ipsilateral medial longitudinal
fasciculus
D. Contralateral paramedian pontine reticular formation and the ipsilateral medial longitudinal
fasciculus
E. Bilateral medial longitudinal fasciculi

Answer 4

C. Ipsilateral paramedian pontine reticular formation and the ipsilateral medial longitudinal
fasciculus

Question 5

Optic nerve sheath meningiomas present with
what characteristics?
A. Arising from the dural layer of the meninges
lining the intraorbital or intracanalicular optic
nerve
B. Painless, slowly progressive monocular vision
loss
C. Optociliary shunt vessels without optic
atrophy
D. Best treated with surgical resection while
there is stability of the vision defect
E. Most commonly affecting young women with
an incidence three times that in men

Answer 5

B. Painless, slowly progressive monocular vision
loss

Question 6

A patient incurs an infarction of the midbrain and
develops a right trochlear nerve deficit as manifested on clinical exam. For what should the examiner look in the contralateral eye to localize the
extent of the lesion?
A. Mydriatic pupil
B. Abducens nerve deficit
C. Horner syndrome
D. Oculomotor palsy

Answer 6

C. Horner syndrome

Question 7

A patient presents with a pupil that is tonically
dilated with a very slow reaction to light. During
accommodative testing, there is a more pronounced constriction. Syphilis and dorsal midbrain
syndrome are ruled out through workup. Between
what two neurons in the pupillary reflex pathway
is the lesion?
A. Prior to the first neuron
B. Between the first and second neurons
C. Between the second and third neurons
D. Between the third and fourth neurons
E. After the fourth neuron

Answer 7

D. Between the third and fourth neurons

Question 8

A 60-year-old woman presents with a 1-year history of progressive irritability, right-sided anosmia,
and decreased right-sided vision. A funduscopic
exam shows left-sided papilledema. What is the
most likely lesion?
A. A large, left parasagittal meningioma
B. A right olfactory groove meningioma
C. A suprasellar glioma
D. A left sphenoid wing meningioma

Answer 8

B. A right olfactory groove meningioma

Question 9

What factor predicts the occurrence of Terson
syndrome following aneurysmal subarachnoid
hemorrhage?
A. Hunt-Hess score
B. Ventriculomegaly
C. Fisher grade
D. Anterior communicating artery aneurysm

Answer 9

A. Hunt-Hess score

Question 10

A patient closes his eye forcefully, and it is noted
that his eye slowly opens after several seconds
despite his efforts to keep it closed. What is the
likely diagnosis?
A. Myasthenia gravis
B. Hemifacial spasm
C. Hemifacial paresis due to stroke
D. Disinsertion of the levator palpebrae
E. Botulinum toxin injection into the orbicularis
oculi

Answer 10

A. Myasthenia gravis

Question 11

A 13-year-old girl presents to the emergency room
for the third time in a year with an acute occurrence of a severe, bifrontal headache (worse on the
right) with right orbital pain. She endorses photophobia, nausea, and diplopia. Exam reveals a right
oculomotor nerve palsy that the patient states has
occurred with past headaches. MRI and MR angiography of the brain are done and are unremarkable. What is the likely diagnosis?
A. Multiple sclerosis
B. Ophthalmoplegic migraine
C. Myasthenia gravis
D. Classic migraine
E. Orbital cellulitis

Answer 11

B. Ophthalmoplegic migraine

Question 12

Which of the following is a characteristic of optic
nerve gliomas?
A. They most commonly are pilocytic astrocytomas, WHO grade IV.
B. Seventy percent occur in the third decade of
life.
C. They present with optic atrophy and disk
edema with an afferent pupillary defect.
D. Surgical resection is the first-line treatment.
E. They are associated with neurofibromatosis
type 2.

Answer 12

C. They present with optic atrophy and disk
edema with an afferent pupillary defect.

Question 13

Where does the Goldman visual field test result
shown in this image localize the patient’s lesion?
A. Inferior arcuates of the retina
B. Superior arcuates of the retina
C. Optic nerve
D. Optic tract
E. Occipital lobe

Answer 13

B. Superior arcuates of the retina

Question 14

A 65-year-old man presents with a severe headache and painful ophthalmoplegia unilaterally that
has occurred previously with spontaneous remission each time. An MRI of the body is done, revealing only inflammatory changes in the cavernous
sinus, and cerebrospinal fluid studies only reveal a
mild lymphocytic pleocytosis. Serum angiotensinconverting enzyme levels are within normal limits.
What is the patient’s likely diagnosis?
A. Ramsay Hunt syndrome
B. Tolosa-Hunt syndrome
C. Sarcoidosis
D. Multiple sclerosis
E. Tuberculosis meningitis

Answer 14

B. Tolosa-Hunt syndrome

Question 15

A 23-year-old woman is referred to the ophthalmologist for unilateral optic disk edema and a painless decrease in visual acuity in the same eye. She
endorses headaches and has a body mass index of
38. Funduscopic examination reveals macular exudates in a “star” pattern. What is the most likely
cause of her findings?
A. Pseudotumor cerebri
B. Optic nerve glioma
C. Infectious neuroretinitis
D. Glaucoma
E. Nonarteritic anterior ischemic optic neuropathy

Answer 15

C. Infectious neuroretinitis

Question 16

A woman presents to the neurosurgery clinic complaining of unilateral diplopia after a 5-cm right
convexity meningioma was found on MRI. She has
been started on phenytoin. What is the most likely
cause of the patient’s diplopia?
A. Cranial nerve palsy secondary to the
meningioma
B. Cranial nerve palsy secondary to unreported
trauma
C. Congenital strabismus
D. Phenytoin side effect
E. Refractive error

Answer 16

E. Refractive error

Question 17

What is the prognosis for a patient undergoing a
12-hour spinal surgery with extensive blood loss
who wakes up with bilateral loss of vision (light
perception only)?
A. Complete recovery of vision in the acute
period
B. Complete recovery of vision in a delayed
fashion
C. Partial recovery of vision
D. Variable prognosis with some patients having
good and others having poor vision outcomes
E. Poor prognosis with little recovery of vision

Answer 17

E. Poor prognosis with little recovery of vision

Question 18

A 70-year-old man presents with 2 weeks of a tender right scalp and profound vision loss in the right
eye. Cotton-wool spots are seen on funduscopic
exam. C-reactive protein is elevated, and the patient
has been on low-dose steroids for 1 week as prescribed by another physician. What is the next step
in management?
A. Start high-dose steroids
B. Plasmapheresis
C. Schedule fluorescein angiography
D. Schedule temporal artery biopsy
E. Observation

Answer 18

A. Start high-dose steroids

Question 19

What are considered the maximal safe doses of
radiation to the visual pathways and optic
apparatuses?
A. < 25 Gy total and < 1 Gy fractionated
B. < 50 Gy total and < 2 Gy fractionated
C. < 75 Gy total and < 4 Gy fractionated
D. < 100 Gy total and < 8 Gy fractionated
E. < 8 Gy total

Answer 19

B. < 50 Gy total and < 2 Gy fractionated

Question 20

How is isolated optic neuritis associated with multiple sclerosis (MS) during 15-year follow-up?
A. MS will not occur if MRI is negative for lesions
at the time of the optic neuritis.
B. More than one demyelinating plaque at the
time of optic neuritis indicates an almost 100%
chance of developing MS.
C. Severe optic disk swelling and optic disk hemorrhage are associated with an increased risk
for developing MS.
D. There is a 50% risk of developing MS across all
patients with optic neuritis.

Answer 20

D. There is a 50% risk of developing MS across all
patients with optic neuritis.

Question 21

A 38-year-old obese woman presents to the neuroophthalmology clinic with symptoms suggestive of
pseudotumor cerebri. After mass lesions are ruled
out, what is the next disease process that must be
ruled out using neuroimaging?
A. Empty sella syndrome
B. Flattening of the posterior aspect of the globes
C. Dural venous sinus thrombosis
D. Thyroid disease
E. Vitamin A deficiency

Answer 21

C. Dural venous sinus thrombosis

Question 22

What investigation is expected to have the highest
chance of yielding positive results in a 41-year-old
obese patient who presents with bilateral acute
optic neuropathy following rapid weight loss?
A. Methylmalonic acid and homocysteine levels
B. Thorough family/genetic history
C. MRI of the orbits
D. History of homemade alcohol consumption

Answer 22

A. Methylmalonic acid and homocysteine levels

Question 23

A 55-year-old man presents with a third nerve
palsy. MRI of the brain is unremarkable. What is
the most likely diagnosis?
A. Posterior communicating artery aneurysm
B. Trauma
C. Myasthenia gravis
D. Vaso-occlusive disease
E. Multiple sclerosis

Answer 23

D. Vaso-occlusive disease

Question 24

A patient with anisocoria has a reversal of his
anisocoria with apraclonidine administered in the
eyes bilaterally. He notes in his history a lack of
sweating one side of his face only. Amphetamine
administration causes dilation of the originally
miotic pupil. Given the likely diagnosis, what is the
next step in the workup?
A. No further imaging is indicated
B. Orbital imaging
C. Imaging of the medulla with MRI
D. Chest imaging
E. CT angiography of the neck looking for internal carotid artery dissection

Answer 24

D. Chest imaging

Question 25

A patient complains of headaches and declining
visual acuity. The fundus is shown in this image.
What is the next diagnostic test the physician
should perform?
A. Check the hemoglobin A1c.
B. Order a CT of the brain.
C. Check the intraocular pressure.
D. Check the blood pressure.

Answer 25

D. Check the blood pressure.

Question 26

A 15-year old woman is referred to the neuroophthalmologist due to a left esotropia with
abduction limitation. On exam, the patient maintains a constant head turn to the left and squints
with the left eye. She denies trauma, and photographs over the past 10 years show similar head
turns and squinting. What is the most likely
diagnosis?
A. Left abducens nerve palsy
B. Intracranial mass
C. Duane syndrome
D. Multiple sclerosis
E. Unreported trauma

Answer 26

C. Duane syndrome

Question 27

In general, when localizing a pathology resulting
in a bilateral visual cut, how does symmetry of the
deficit assist in the localizing?
A. More symmetrical visual field deficits tend to
localize lesions closer to the occipital lobes.
B. More symmetrical visual field deficits tend to
localize lesions closer to the optic chiasm.
C. More symmetrical visual field deficits tend to
localize lesions closer to the lateral geniculate
nucleus.
D. Symmetry of visual field deficits has no relevance when localizing lesions.

Answer 27

A. More symmetrical visual field deficits tend to
localize lesions closer to the occipital lobes.

Question 28

A patient is referred to his physician due to bilateral exophthalmos. Without any other clinical information being provided, what structure or system
should be the most likely focus of the next step in
the patient’s workup?
A. Thymus
B. Brain
C. Eye
D. Thyroid
E. Bone marrow

Answer 28

D. Thyroid

Question 29

A patient with a ventriculoperitoneal shunt is seen
in the emergency room and is described as having
Parinaud (dorsal midbrain) syndrome secondary
to hydrocephalus. There is eyelid retraction when
the patient is asked to look upward and good convergence when looking downward. What function
of upgaze is expected to be the most conserved?
A. Voluntary upgaze
B. Upgaze with “doll’s eyes” test
C. Upgaze with accommodation
D. Upgaze when lying supine

Answer 29

B. Upgaze with “doll’s eyes” test

Question 30

What is seen in the Goldman visual field of the left
eye shown in this image?
A. Quadrantanopsia
B. Disk edema and enlargement of the blind spot
C. Visual field occlusion due to ptosis
D. Unreliable visual field due to feigning of
symptoms

Answer 30

B. Disk edema and enlargement of the blind spot

Question 31

A patient presents with bilateral extorted eyes.
What is the etiology most considered until proven
otherwise?
A. Demyelination
B. Tumor
C. Congenital
D. Trauma
E. Infarction

Answer 31

D. Trauma

Question 32

Cold water is injected simultaneously into a
patient’s ears. What will be the direction of the
fast phase of nystagmus?
A. Inferiorly
B. Superiorly
C. Left
D. Right
E. Equally to the right and left

Answer 32

B. Superiorly

Question 33

What pathology is shown in this image of the visual
field in the right eye?
A. Pituitary tumor
B. Methyl alcohol poisoning
C. Optic neuritis
D. Left middle cerebral artery territory infarction

Answer 33

C. Optic neuritis

Question 34

Up to what age can strabismic amblyopia be
improved with treatment?
A. 6 years old
B. 8 years old
C. 10 years old
D. 12 years old
E. 14 years old

Answer 34

E. 14 years old

Question 35

A patient with severe acne and fever presents with
a rapidly developing right eye proptosis, chemosis,
slowly reactive pupil, and ophthalmoplegia. In what
direction is the right eye most likely unable to
look?
A. Laterally
B. Medially
C. Superiorly and medially
D. Inferiorly and medially
E. Superiorly and laterally

Answer 35

A. Laterally