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Peds neuro boards, V2 > Ophthalmology / Otology > Flashcards

Ophthalmology / Otology Flashcards

1
Q

Most common genetic cause for congenital visual impairment (1) and other features (3)

A
  1. Leber convenital amaurosis (retinal dystrophy)
  2. Features
    1. Visual impairment beginning a 3-4 months > nystagmus and sluggish pupils
    2. midface hypoplasia
    3. Cognitive / developmental delay
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2
Q

What does this show?

A 
Optic nerve edema from optic neuritis
NOT papilledema (pictured below)
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3
Q

What does this show?

A

Optic disk edema and splinter hemorrhages 2/2 AION

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4
Q

What does this show?

A

Optic atrophy (From longstanding MS)

  • pale, “shrunken” appearing disc
  • pallor extends beyond margins of disc
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5
Q

Location of vertical and horizontal Gaze Centers

A
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6
Q

Centers for:
Saccaddes
Pursuit

A
  1. Saccades
    1. Contralateral frontal lobe
  2. Pursuit
    1. Ipsilateral parietal / occipital
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7
Q

nerve most commonly injured in head trauma

A

CN IV

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8
Q

Midbrain:
Structures (7)
Locations of Injury (2)

A
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9
Q

Lesions of the third Nerve Nuclei

A
        1. Superior rectus nucleus (Contralateral)
  2. Levator nucleus (levator palpebrae)
    1. NOTE: single nuclei controls both eyes
      6.
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10
Q

Patient arrives with right CN III nuclear palsy:

how do you tell if the levator nuclei was damaged?

A
  1. levator nuclei
    1. Bilateral ptosis (injured) or NO ptosis at all (not injured)
  2. Superior rectus nuclei
    1. Injured = left SR is damaged
    2. not injured: NO SR damage
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11
Q

Patient arrives with right CN III palsy and bilateral ptosis

what was damaged?

A

CN III nuclei with invovlement of levator palpebare nucleus

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12
Q

Pons Anatomy (9)

A
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13
Q

Patient arrives with isolated CN III palsy
What is the significance of also having:

Contralateral hemiparesis? (3)
Contralateral hand tremor? (3)
Cerebellar ataxia? (3)
Contralateral hand tremor AND cerebellar ataxia?

A
  1. Contralateral hemiparesis = Weber
    1. CN III fascicle
    2. pyramidal tract
  2. Contralateral hand tremor = benedikt syndrome
    1. CN III fascicle
    2. Red nucleus
  3. Cerebellar ataxia = Nothnagles
    1. CN III fascicle
    2. superior cerebellar peduncle
  4. Both 2 and 3 = claude’s syndrome
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14
Q

Patient arrives with Abducens palsy
what is the significance of also having:

Ipsilateral Facial palsy + Contralateral Hemiparesis (4).

Ipsilateral loss of facial sensation, facial palsy, and horners syndrome?

A
  1. VI, VII palsy + CL hemiparesis = Millard-Gubler syndrome
    1. VI fascicles
    2. VII fascicles
    3. Pyramidal tract
  2. Facial sensation, facial palsy, and horners = Fovile’s syndrome
    1. CN V
    2. CN VI nucleus
    3. CN VII nucleus and sympathetics
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15
Q

Why does blown pupil with CN III raise concerns?

A

Nerve fibers corresponding to pupillary constriction are in the periphery, and thus are targeted during compressing lesions (like aneurysm)

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16
Q

Features of Dorsal Midbrain syndrome

A

Vertical gaze palsy

Convergence - retraction nystagmus

lid retraction

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17
Q

Patient comes in with:
Vertical gaze Palsy
lid Retraction
Pulsating in-and-out movements of eyes with vertically moving OKN drum

Where is the lesion?
what are you suspecting as the cause?
what would you not expect to see?

A

Dorsal midbrain (Dorsal midbrain syndrome)

suspect:
OLD = Stroke
young = Pinealoma

would NOT expect to see pupillary light-near dissociation

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18
Q

Patient unable to look left, but eyes look left when head is passively turned to the right

what does this tell you?

A

This is a supranuclear lesion due to positive doll’s eye maneuver

(possibly due to frontal lobe stroke)

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19
Q

Horizontal or vertical gaze palsy but positive Doll’s eye in that direction suggets what?

A

supranuclear lesion

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20
Q

What does this show?

what is damaged?

What two other features will you see?

A

Bilateral Intranuclear ophthalmoplegia (bilateral limitation of ADDuction)

Damage to medial longitudinal fasciculus

Will also see:
beating nystagmus of adducting eye
vertical skew deviation = vertical diplopia

(#2)

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21
Q

What does this show?

what is the syndrome?

A

Right horizontal Gaze palsy + Right medial rectus palsy when looking left

One-and-a-half-syndrome

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22
Q

“Painful horners”

Make sure to rule out what?

What should you also see (3)?

A

Carotid Dissection

Vision loss IL to horners
Headache IL to horners
CL hemiparesis

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23
Q

What is damaged here?

What will worsen the pupillary finding?

A

Sypathetic innervation to the right eye (horners)

Anisocoria will be more evident in DIM light (sympathetics / Dilation is what is affected)

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24
Q

How would we confirm this diagnosis?

Option 1:
what drug?
what do you see?

Option 2:
what drug?
what do you see?

A

Option 1: Cocaine

  1. Affected Pupil will NOT dilate

Aproclonidine

  1. Affected WILL dilate
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25
Q

Threshold for physiologic anisocoria

A

<1-2 mm

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26
Q

What is this showing?

What does this suggest?

If this wasn’t present, what would you want to exclude?

A

Horners syndrome with hypochromia of the iris

congenital horners (also feed into melanocytes of eye)

pediatric acquired horners = r/o pineoblastoma

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27
Q

Woman with this eye finding and “wiggly” pupillary movements.

What other finding would you see?

How would you test?

A

Light-near dissociation (picture)

Dilute Pilocarpine
Will cause constriction (because it’s hypersensitive)

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28
Q

Woman with this eye finding and “wiggly” pupillary movements.

what is injured?

what are the two most common causes?

A

Ciliary gangion
“wiggly” = vermiform movements

most common causes:
post-viral
trauma / surgery to eye

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29
Q

What does this show?

What conditions can you see it in (3) ?

A

Light-Near dissociation

Seen in:
Argyll-Robertson pupil (tertiary syphilis)
Parinaud’s dorsal midbrain syndrome (stroke in adult, pinealoma in children)
Adie’s tonic pupil (post-viral or post-surgery)

(accomodates but does not react)

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30
Q

Label the Following:

A
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31
Q

Diseases associated with

Unilateral central scotoma

Bilateral central scotoma

A

Unilateral central scotoma = optic neuritis / MS

Bilateral = toxic / medication

  • Ethambutol for tuberculosis
  • Thiamine deficiency
  • Leber’s hereditary neuropathy
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32
Q

leber’s hereditary neuropathy:

Vision problems are worse with _____

A

Smoking

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33
Q

Difference between pituitary microadenoma and pituitary macroadenoma and why is it imporant?

A 
Microadenoma = \<10 mm
macroadenoma = \>10 mm

> 10 mm and you are more likely to have visual impairment

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34
Q

Patient reports loss of vision only when sketching fine details in sketchbook

what tumor could cause this?
what is it typically associated with?

A

Tumor in optic chiasm (i.e. Pineal tumor)

typically associated with bitemporal hemianopsia

when convergin, “blind” temporal fields overlap

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35
Q

What should this make you worry about?

A

Central lesion (bow-tie atrophy)

36
Q

What is this showing?

what causes this finding?

A

Junctional scotoma
central scotoma in one eye + suprerotemporal defect in other eye

Lesion to anterior part of chiasm
infranasal fibers move up to opposite optic nerve before decussating (Von Wilbran’s knee)

37
Q

What is this showing?

what is it suggestive of?

what should NOT be affected?

A

Homonimous field defect with weird wedge

damage to lateral geniculate nucleus lesion

pupillary light reflex should NOT be affected

38
Q

What is this showing?

What does this suggest?

A

“pie in the sky” defect

right temporal lobe defect

39
Q

What oculomotor finding are suggestive of parietal lobe lesion?

A

Defects in OKN drum

(persuit / saccade)

40
Q

Label the following and the associated Visual fields

A
41
Q

Match the following with the visual field defect

A
42
Q

What is this?
features (2)

Vision?

What is it seen in (3)

Epidemiology note

A

Morning glory Disk
Funnel-shaped staphyloma
radial vessels

Poor vision (hand motion)

Seen in:
serous retinal detachment
basal encephalocele

signifies vascular development failure

43
Q

What causes this?

A

Incomplete closure of embryonic fissure

Also associated with
visual field defects
relative Afferent pupillary defect RAPD

44
Q

What non-neurologic evaluation should this person get?

A

(optic nerve hypoplasia)

Endocrine evaluation (due to midline defects)

45
Q

Conditions associated with this finding

A

(optic nerve hypoplasia)

Associated with:
midline hemispheric defects

maternal DM, drug, EtOH

46
Q

Retina Versus Visual field

Nasal retina
Temporal retina

A

Nasal retina = Temporal visual field

Temporal retina = nasal visual field

47
Q

What tests could you order to confirm this finding?

A

calcified nodules (drusen)

CT

48
Q

What can cause this?

A

Bilateral lateral compression of chiasm

such as calcivfied internal carotid arteries

49
Q

Function of inferior oblique
inferior rectus

A

Inferior oblique: Elevates and Extorts
inferior rectus: depresses and extorts

“inferiors extort”

50
Q

what structure is responsible for circadian rhythms?

A

Suprachiasmic nucleus (hypothalamus)

51
Q

Terms:

internal ophthalmoplegia
VS
external ophthalmoplegia

A

Internal ophthalmoplegia: loss of parasympathetic innervation to sphincter papillae (results in miadriasis)

External ophthalmoplegia = paralysis of external ocular muscles

52
Q

Cranial nerve Palsies which spare the pupil (3)

A

“Inside the I, it is DiM

  • *I_ncomplete _I**schemic lesions
  • *D**iabetes, Myasthenia
53
Q

Ciliary nerves responsible for:

pupil Dilation
pupil constriction

A

Pupil dilation: Long ciliary nerve

Pupillary constriction: Short ciliary nerve

54
Q

Emboli to the Eye and what they signify:

Small, shiny emboli to the eye lodged in retinal arteriole

Gray, globular emboli completely occluding retina

Long, gray emboli

A
  1. Hollenhorst plaque:
    1. signififies prior ischemic damage to eye (treating upstream vessel may prevent further embolization injury)
  2. Calcific emboli: disease heart valves
  3. Platelit-fibrin emboli: endogenous
55
Q

Baby comes in with Infantile spasms and Agenesis of the corpus callosum

Why is this in the “ophthalmology” slide deck?

A

Aicardi syndrome can have chorioretinal Lacunae, look for it.

AICardi
Ageneis of corpus callosum
Infantile spasms
Chorioretinal Lacunae

56
Q

Lens Deviation:

upwards deviation, think _____

downwards, think ____

A

Upwards = marfans

Downwards = Homocystinuria

57
Q

Dancing eyes, dancing feet

What do you look for in child (2)
what do you look for in adult (4)

A

Child

  1. Urine catecholimines due to neuroblastoma

Adult

  1. Anti-Ri due to cancer of (anti-R_epublican _BL_o_G)
    1. Breast
    2. Lung
    3. Gynecologic
58
Q

Slow vertical saccades + square-wave jerks suggest what?

A

Progressive supranuclear palsy

59
Q

Woman with MS-like lesions but bilateral retinal artery occlusions:

What do you think about?
what are it’s features?

A

Susac’s syndrome

Bilateral retinal artery occlusions
Encephalopathy
sensorineural hearing loss

60
Q

Mnemonic for Whipple’s disease

A

My Super Duodenum Smells Like We Can’t Digest Nothing

Classic triad:

  • Myoclonus
  • supranuclear palsy
  • dementia

Other features

  • Steatorrhea
  • Lymphadenopathy
  • Weight loss
  • Convergence/Divergence Nystagmus (pendular nystagmus with simultaneous jaw movements; whipple’s eyes)

Caused by trophermya whippelii (PAS +)

61
Q

Hallucination roundup:

  1. Formed hallucinations
  2. unformed visual hallucinations
  3. real objects look malformed, smaller, or larger
  4. Hypnogogic / hypnopompic
  5. pendular hallucinations
A
  1. Formed hallucinations = Temporal lobe epilepsy
  2. unformed visual hallucinations = occipital lobe epilepsy
  3. Malformed (metamorphosia), smaller (micropsia), larger (macropsia) = migraine
  4. Hypnogogic / hypnopompic = narcolepsy
  5. Pendular = midbrain injury
62
Q

Thalalamic nuclei for vision and hearing

A

L = Light (lateral geniculate nucleus)

M = Music (Medial geniculate nucleus)

63
Q

Dix Hallpike Maneuver:

How do you do it?
What constitutes a “positive” test?

A

How to do it:

  • Start in reclining position with head back roughly 20 degrees
  • Tilt head 45 degrees and bring patient up from reclining to sitting position

Positive result:

  • Upward nystagmus when patient is reclining
  • downward nystagmus when sitting up
64
Q

45- year old man complains of Vertigo, tinnitus and “fullness” in ears

What does he have?
what else would you expect (2)?
What 3 things should he avoid?

A

Menier’s disease u

  • Features
    • Vertigo with “fullness” in ears
    • Tinnitus
    • Low-frequency hearing loss (compared to high frequency associated with loud sound exposure)
    • +/- horizontal nystagmus
  • Risk factors
    • Excessive salt intake
    • head trauma
    • Cigarette / EtoH use
65
Q

Infant presents with sensorineural hearing loss:

  1. Name 4 congential infections that could cause this
  2. If also has retinitis pigmentosa, what could this be?
  3. If no RP but instead Goiter is present, what could this be?
A
  1. Congential infections causing sensorineural hearing loss
    1. Toxoplasmosis
    2. CMV
    3. Rubella
    4. HSV
  2. Sensorineural hearing loss + RP suggests usher syndrome
  3. Sensorineural hearing loss + goiter suggest Pendred syndrome.
66
Q

Older man comes in with unsteady gait, incontinence, dementia, and tinnitus.

What does the tinnitus sound like?

A

Venous Hum (pulsatile tinnitus with NPH)

67
Q

What common prophylactic drug can result in subjective tinnitus

A

Aspirin

68
Q

Differe AION versus NAION

A

AION = more likely to have superior altitudinal defects (also seen with glaucoma)

NAION more likely to have inferior

69
Q

Label the following and important elements of each

A
  1. Red = cochlear promontory
    1. site of glomus tympanic paragangliomas
  2. Purple = tympanic segment of facial nerve
  3. Blue = Tegmen tympani
    1. separates cranial and tympanic caveties
  4. Orange = Malleus
    1. one of the ossicles of middle ear
  5. Yellow = Scutum
    1. first bony structure to be eroded by enlarging cholesteatoma
70
Q

Patient presents with peripheral vertigo

How should their eyes move?

A

Horizontal / rotary nystagmus directed with fast phase away from affected size

71
Q

“horners but with intact sweating”

What study should he get?

A

MRA to check for carotid dissection

(“post-ganglionic horners”)

72
Q

Child is unable to hear soft voices in quiet background, but can hear loud voices in a noisy background?

What does this suggest?

A

Conductive hearing loss

(opposite would be sensorineural)

73
Q

Patient with Vertigo only during severe storms and conductive hearing loss

What is this called?
What does he have?
How would you confirm diagnosis?

A

Superior semicircular canal dehiscence syndrome

Tullio’s phenomenon (sound-induced vertigo)

Confirm with Hennebert sign (pressure-induced vertigo)

74
Q

How would you treat this patient?

A

Iodine / steroids / immunosuppression / referral to endocrinology

(Graves disease, note sparing of lateral rectus, this is characteristic of Graves)

75
Q

Patient pesents with Pigmentary retinopathy. What medications would you worry about if patient has:

Autoimmune conditions (2)
schizophrenia (2)
HIV (1)
Cancer (2)

A
  • Autoimmune conditions
    • Chloroquine
    • Hydroxychloroquine
  • Schizophrenia
    • Thioridazine
    • chlorpromazine
  • HIV
    • Ritonavir
  • Cancer
    • Cisplatin
    • BCNU
76
Q

Best test to localize Horners syndrome and findings

A

Hydroxyamphetamine

Dilates normally after administration: 1st or 2nd order motor neuron disease

77
Q

Patient presents with bilateral fluctuating hearing loss, episodic vertigo, and interstitital keratitis.

How do you treat?

A

Cogan’s syndrome

Treat with high dose steroids followed by immunosuppression if unresolved

78
Q

Patient presents with gaze-evoked and vestibular nystagmus

What is this called?

What can this indicate?

A

Bruns nystagmus

Larege cerebellopontine angle tumor (such as vestibular schwannoma)

79
Q

Factors associated with poorer prognosis in PRES

A

Corpos callosum involvent

80
Q

Define Saccadomania (2)

A
  1. Flutter - random horizonal eye movements (MS)
  2. Opsoclonus”: random, chaotic, multiplanar eye movements
81
Q

Brain regions and associated wye movements

Saccades :
smooth pursuit:

Additional note for optokinetic drumq

A

Saccades: contralateral frontal lobe
pursuit: IL pareito/occipital lobe (ill-defined)

Note on optokinetic drum: Allows you to assess one side of brain for each (smooth pursuit followed by saccade in other direction)

82
Q

Patient presents with opsoclonus. What do you think of it patient is…

A child

An adult

A

Child: neuroblastoma

Adult: paraneoplastic

83
Q

What regions are responsible for:

Saccades
Pursuit

A

Saccades (FAST): contralateral frontal lobe

Pursuit (slow): ipsilateral parietooccipital region (ill-defined)

84
Q

Patient presents with optokinetic nystagmus. what has been damaged?

parietal lobe lesion ipsilateral to where smooth persuit is lost.

A
85
Q

Reaction of eye drops in horners

Aproclonidine
Cocaine
1% hydroxyamphetamine

A
  1. Aproclonidine
    1. affected pupil dilates, affected lid elevates
  2. Cocaine
    1. unaffected eye will dilate
  3. Hydroxyamphetamine
    1. dilation if affected eye if 1st or 2nd order neuron

Peds neuro boards, V2 (29 decks)

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