optic nerve Flashcards
Which 4 of the following nerves are strictly MOTOR in function? (Select 4)
Cranial nerve I Cranial nerve IV Cranial nerve VI Cranial nerve II Cranial nerve XI Cranial nerve III
Cranial nerve IV
Cranial nerve VI
Cranial nerve XI
Cranial nerve III
CN1,2,8 -> sensory
CN5,7,9, 10 –> both
Which 2 of the following pupil anomalies would cause anisocoria that is more prevalent in bright lighting? (Select 2)
Oculomotor palsy Horner's syndrome Acute Adie's tonic pupil Physiologic anisocoria Marcus Gunn pupil Argyll Robertson pupil
Oculomotor palsy
Acute Adie’s tonic pupil
More prevlalent in bright light = CAN NOT constrict 1- ADIES 2-CN3 palsy 3- pharmglogical agent 4- iris sphincter damage
A 9-year old patient presents with a unilateral ptosis of the left eyelid that improves in position when he widely opens his jaw. This condition, known as Marcus-Gunn jaw winking, is the result of aberrant connections between which 2 of the following cranial nerves? (Select 2)
Cranial nerve III Cranial nerve VI Cranial nerve II Cranial nerve V Cranial nerve VII Cranial nerve IV
CN3,CN5
Marcus-Gunn jaw winking is a phenomenon that is thought to occur as a result of an abnormal connection between cranial nerve V and cranial nerve III. Branches from the motor root of the trigeminal nerve that are meant for the ipsilateral pterygoid muscle aberrantly connect with the ipsilateral levator muscle instead. This allows for an elevation effect of the upper eyelid when jaw movements are initiated. This type of aberrant innervation may occur in up to 5% of patients presenting with a congenital ptosis; it tends to lessen in severity with age. This condition should not be confused with aberrant regeneration of cranial nerve VII; it is an isolated neurologic finding and does not require further work-up. Furthermore, Marcus-Gunn jaw winking is typically monitored indefinitely unless there is cosmetic concern and/or surgical intervention is desired.
A patient with bilateral tilted discs whose crescents are inferior and nasally displaced will typically display a defect located along which portion of the visual field test?
Superior temporal
Inferior nasal
Superior nasal
Inferior temporal
Superior temporal
Which area of the retina naturally corresponds with a sensitivity of 0 decibels on visual field testing?
The papillomacular bundle The macula The inferior arcade The optic nerve head The superior arcade
The optic nerve head
The optic nerve head, also known as the blind spot, will demonstrate a sensitivity of 0 decibels, because this area of the eye does not contain any visual receptors, and therefore does not possess any viable vision. The area of the retina with the highest decibel level (hence the highest sensitivity) as seen with visual field testing is the fovea. The sensitivity to stimuli decreases with increasing distance from the fovea.
Which of the following vessels provides the majority of the blood supply to the optic nerve head?
Long posterior ciliary arteries
Central retinal artery
Anterior ciliary arteries
Short posterior ciliary arteries
Short posterior ciliary arteries
Which of the following pupillary fibers is damaged in patients presenting with an Adie’s tonic pupil?
Pre-ganglionic parasympathetic
Post-ganglionic parasympathetic
Pre-ganglionic sympathetic
Post-ganglionic sympathetic
Post-ganglionic parasympathetic
Which 2 of the following signs and symptoms can aid in differentiating between a microvascular and compressive third cranial nerve palsy? (Select 2)
The presence of pain is more common in aneurysmal third nerve palsies
Aberrant regeneration typically result from microvascular third nerve palsies
Microvascular third nerve palsies do not typically involve the pupil
Third nerve palsies due to compressive lesions will always have an affect on pupil size
Third nerve palsies associated with microvascular disease commonly spontaneously resolve within 3 months
Microvascular third nerve palsies do not typically involve the pupil
Third nerve palsies associated with microvascular disease commonly spontaneously resolve within 3 months
There are several signs and symptoms that clinicians utilize in order to aid in differentiating between microvascular and compressive third nerve palsies. Some of these are summarized below:
- Third nerve palsies associated with microvascular disease commonly spare the pupil due to the superficial location of pupillary fibers as they travel in the nerve
- Third nerve palsies associated with compressive lesions commonly involve the pupil due to compression of the superficial pupil fibers
- It is important to note that this is only a general principle; there are several cases in which compressive lesions do not affect the pupil initially but may eventually if the lesion continues to grow (also, some diabetic palsies have been shown to cause pupil dilation)
- Third nerve palsies due to microvascular lesions will typically resolve within a period of three months (if a suspected microvascular lesion does not resolve within this time, imaging must be completed)
- Aberrant regeneration will only occur following acute traumatic or compressive third nerve palsies (but never after a microvascular palsy) due to the fact that the endoneural nerve sheaths remain intact in vascular pathology
- The presence of pain is common in both diabetic and aneurysmal third nerve palsies; therefore, it cannot be used to differentiate the two
A healthy retinal nerve fiber layer is thickest at which portion of the optic nerve head?
Superiorly
Temporally
Inferiorly
Nasally
inferior
ISN’T rule
thickest is Inferior , superior –> first get affected in glaucoma
You are performing a slit-lamp examination on your 37 year-old male patient. He is having difficulty keeping his eyes open due to the bright light. This is an example of which of the following reflexes?
Menace Pupil Facial Corneal Dazzle
answer is Dazzle –>bilateral narrowing of the palpebral fissures
Menace –>bilateral reflexive closure of the eyelids when OBJECT get closer
The trigeminal nerve has three main divisions. Which of the following corresponds to division 1 of the trigeminal nerve (V1)?
Ophthalmic division Infratrochlear Posterior ethmoid Long ciliary Supraorbital
ophthalmic
CN5 = trigeminal
v1–> ophthalmic(NFL)
Nasociliary ( LINES ),long ciliary ,inferior trochlear ,nasocailiary,ethmoid,short ciliary
Frontal–> supraorbital and the supratrochlear
v2-> maxillary
v3–> mandibular
Which of the following medications has been identified as a risk factor for the development of non-arteritic anterior ischemic optic neuropathy (NAION)?
Simvastatin Hydrochlorothiazide Sildenafil Celecoxib Omeprazole Atenolol
Sildenafil
VIAgra
Viagra= slidenafil
imitrex
amiodarone
Which of the following conditions has been associated with an intact pupillary light response and absent near response?
Aberrant regeneration of the third nerve Myotonic dystrophy There is no clinical condition in which this exists Diabetes Adie's tonic pupil Neurosyphilis
There is no clinical condition in which this exists
but
dissociation of light and near responses in which the light reflex is either absent or sluggish and the near response is normal.
What is the correct order of the optic nerve meninges progressing from most external to most internal?
Dura mater, arachnoid, pia mater Arachnoid, dura mater, pia mater Dura mater, pia mater, arachnoid Pia mater, arachnoid, dura mater Arachnoid, pia mater, dura mater
Dura mater, arachnoid, pia mater
Which of the following optic nerve conditions results from an increase in intracranial pressure?
Papilledema
Ischemic optic neuropathy
Papillitis
Optic neuritis
Papilledema
Papilledema is defined as passive swelling of the optic disc caused by increased intracranial pressure, usually as a result of intracranial tumors or malignant hypertension. The condition is almost always bilateral, and vision is usually normal unless there is associated edema or exudates in the macular area.
Optic neuritis is inflammation of the optic nerve that can occur at any location as it courses from the eye. It is typically caused by swelling and destruction of the myelin sheath that surrounds the nerve.
Papillitis is a specific type of optic neuritis in which there is an inflammation of the optic nerve head. This condition is almost always unilateral, and because the optic nerve is inflamed, it is commonly associated with vision loss.
Ischemic optic neuropathy is caused by obstruction of blood flow to the optic nerve, resulting in the loss of structure or function of a portion of the nerve. It is classified as either arteritic or non-arteritic, according to the location of the nerve that is affected. Patients with this condition will often present with acute loss of visual acuity and an altitudinal visual field defect.
A college student presents with bilateral internuclear ophthalmoplegia (INO). This finding is pathognomonic for which one of the following?
Lyme disease
Multiple sclerosis
Pseudotumor cerebri
Bell’s palsy
answer is Multiple sclerosis= BILATERAL INO in young
older with bilateral INO = vascular defect or stroke.
INO= dysfunction of medial longitudinal fasciculus.
IPSI –> can not ADduct
contra –> Nystagmus
Which of the following BEST describes the rotation of the eyeball during Bell’s phenomenon?
Downward and inward
Upward and inward
Upward and outward
Downward and outward
Upward and outward
Bell’s phenomenon is a reflex coordinated between the facial nerve and the oculomotor nuclei in which the eyeball is rotated upward and outward upon closure of the eyelids
hich of the following sequences describes the correct order of the oculosympathetic pathway as the neurons descend from the brain?
Hypothalamus–> ciliospinal center of Budge–> superior cervical ganglion–> ophthalmic division of trigeminal nerve
Pretectal nucleus–> superior cervical ganglion–> ciliospinal center of Budge–> ophthalmic division of trigeminal nerve
Pretectal nucleus–> ciliospinal center of Budge–> superior cervical ganglion–> ophthalmic division of trigeminal nerve
Hypothalamus–> superior cervical ganglion–> ciliospinal center of Budge–> ophthalmic division of trigeminal nerve
Hypothalamus–> ciliospinal center of Budge–> superior cervical ganglion–> ophthalmic division of trigeminal nerve
The oculosympathetic pathway contains three neurons as it courses from the brain to structures of the eye. The first neuron (central neuron) in this pathway begins at the posterior region of the hypothalamus. It descends down the brainstem to synapse at the ipsilateral ciliospinal center of Budge, which lies between C8 and T2 of the spinal cord. The second neuron (pre-ganglionic neuron) traverses a long course from the ciliospinal center to the superior cervical ganglion in the neck region. During its path, it is closely related to the apical area of the lung where it can be damaged by a Pancoast tumor, or in some cases, during surgery on the neck. The final neuron in the oculosympathetic pathway (post-ganglionic neuron) ascends with the internal carotid artery where it eventually enters the cavernous sinus and joins with the ophthalmic division of the trigeminal nerve. From here, the sympathetic fibers reach the pupil dilator and ciliary body by means of the long ciliary nerves and nasociliary nerves.
Which 3 of the following extraocular muscles are supplied by the MEDIAL muscular branch of the ophthalmic artery? (Select 3)
Inferior oblique Superior rectus Superior oblique Medial rectus Inferior rectus Lateral rectus
Inferior oblique
Medial rectus
Inferior rectus
The medial muscular branch of the ophthalmic artery supplies the medial rectus, inferior rectus, and the inferior oblique extra-ocular muscles, while the lateral muscular branch supplies the superior rectus, superior oblique, lateral rectus, and levator palpebrae superioris.
Which of the following is the correct order of structures through which the pupillary fiber pathway passes?
Optic nerve-> optic chiasm -> Lateral geniculate nucleus in the thalamus-> Edinger-Westphal nucleus
Optic nerve -> optic chiasm -> optic tract -> Lateral geniculate nucleus in the thalamus
Optic nerve -> optic chiasm -> optic tract -> pretectal region of the midbrain -> Lateral geniculate nucleus in the thalamus
Optic nerve -> optic chiasm -> brachium of the superior colliculus -> pretectal region of the midbrain -> Edinger-Westphal nucleus
Optic nerve -> optic chiasm -> brachium of the superior colliculus -> pretectal region of the midbrain -> Edinger-Westphal nucleus
The pupillary fibers exit the eye through the optic nerve and pass through the optic chiasm, where they then exit the optic tract and enter into the brachium of the superior colliculus and synapse onto cells in the pretectal area of the midbrain. The pathway then continues and stimulates intercalated neurons, which in turn stimulate cells in the Edinger-Westphal nucleus. The axons of the pupillary pathway never enter the lateral geniculate nucleus.
Which of the following ocular conditions will NEVER produce a relative afferent pupillary defect in the ipsilateral eye?
Optic nerve glioma Mature cataract Total retinal detachment Central retinal artery occlusion Optic neuritis
Mature cataract
Which layer of the retina is present at the optic disc?
The outer plexiform layer
The outer nuclear layer
The nerve fiber layer
The external limiting membrane
The nerve fiber layer
The nerve fiber layer The disc serves as the convergent axons + nerve fiber layer . The actual optic disc does not contain photoreceptors and thus will not generate nervous signals. This explains why this area is also known as the ‘blind spot’.
Double-ring sign is an observable feature associated with which of the following congenital optic nerve anomalies?
Optic disc coloboma Optic disc dysplasia Optic nerve hypoplasia Morning glory syndrome Megalopapilla Buried optic disc drusen
Optic nerve hypoplasia
Patients with optic nerve hypoplasia present with several characteristic funduscopic features that comprise its diagnosis. Classically, the optic disc is small, has a greyish appearance, and is surrounded by a mottled, yellow, hypo-pigmented peripapillary border that encircles the disc, forming a halo. This halo is also bordered by a darker pigmented ring, which leads to the name “double ring sign.” The outer ring represents what would have been the margin of the disc had it been of normal size.
Which of the following are the MOST common causes of a pupil sparing and pupil involving third nerve palsy, respectively?
Microvascular disease, demyelinating disease
Microvascular disease, compressive lesions
Compressive lesions, microvascular disease
Compressive lesions, demyelinating disease
Demyelinating disease, microvascular disease
Demyelinating disease, compressive lesions
Microvascular disease, compressive lesions
In general, at which location in the eye do axons of the nerve fiber layer become myelinated?
Posterior to the lamina cribrosa
Anterior to the lamina cribrosa
At the equator
Juxtafoveally
Posterior to the lamina cribrosa
A Occasionally, oligodendrites will enter the eye during ebryogenesis causing myelination of the nerve fiber layer. This will appear as a white nerve fiber layer with feathery margins usually extending from the optic disc. In general,
axons within the retina should not be myelinated. Myelination of the nerve fiber layer can be associated with amblyopia, strabismus, nystagmus, optic neuritis, neovascularization of the retina and myopia. However, in most cases, individuals that display this condition are asymptomatic.
While performing confrontation fields, your patient reports seeing all of your fingers when presented on the left and right side of her visual field exclusively; however when your fingers are presented on both sides simultaneously, the patient only reports seeing the fingers on your left hand (her right visual field). What type of lesion is consistent with these findings?
A lesion in the right occipital lobe A lesion in the right frontal lobe A lesion in the left frontal lobe A lesion in the right parietal lobe A lesion in the left parietal lobe
A lesion in the right parietal lobe
she is seeing her right side = can not see her left side = right lesion
A patient presenting with neurosyphilis is MOST likely to exhibit which of the following pupil conditions?
Unilateral Adie's tonic pupil Unilateral Argyll Robertson pupil Bilateral Argyll Robertson pupil Bilateral Adie's tonic pupil Absolute afferent pupillary defect Relative afferent pupillary defect
Bilateral Argyll Robertson pupil= bilateral light-near dissociation
other causes of bilateral light-near dissociation =
diabetes, myotonic dystrophy, Parinaud’s dorsal midbrain syndrome, familial amyloidosis, encephalitis, and chronic alcoholism.
UNILATERAL LIGHT NEAR dissociation = Adie’s tonic pupil, herpes zoster ophthalmicus, and aberrant regeneration of the 3rd nerve.
The ophthalmic portion (V1) of cranial nerve V (the trigeminal nerve) possesses three main sub-divisions. Which of the following is a subdivision of V1?
Mandibular division
Maxillary division
Supratrochlear division
Frontal division
Frontal division
The anterior knee of von Willebrand is composed of optic nerve fibers carrying information from which of the following quadrants of the retina?
Superior-nasal
Superior-temporal
Inferior-nasal
Inferior-temporal
Inferior-nasal
The optic chiasm is formed by the union of the right and left optic nerves. It is in this area that the fibers originating from the nasal retina (temporal visual field) decussate to join the uncrossed temporal fibers (nasal visual field) and course posteriorly as the optic tracts.
The inferior nasal fibers remain low as they traverse the optic chiasm and decussate more anteriorly. Because of their location, these fibers are more vulnerable to damage from expanding pituitary lesions, leading to involvement of the superior temporal visual fields early in the disease. It is also important to note that these inferior-nasal fibers actually loop forward into the contralateral optic nerve before coursing posteriorly in the optic tract. This region is known as the anterior knee of von Willebrand.
The superior nasal fibers remain high as they traverse the optic chiasm and decussate more posteriorly. Therefore, these fibers are typically first involved in cases of lesions growing from above the optic chiasm (craniopharyngiomas), affecting the inferior temporal visual fields early in the disease progression.
The FIRST synapse in the visual pathway occurs in which of the following layers of the retina?
Outer nuclear layer Inner plexiform layer Inner nuclear layer Outer plexiform layer Photoreceptor layer Ganglion cell layer
opl
Which of the following nerves does NOT travel within the lateral wall of the cavernous sinus but rather passes through the middle of the sinus alongside the internal carotid artery?
Ophthalmic branch of trigeminal nerve Maxillary branch of trigeminal nerve Abducens nerve Trochlear nerve Oculomotor nerve
Abducens nerve
Cavernus sinus wall 3,4,, V1,V2
thro body of Cav sinus –> 6, internal carotid
Which of the following cranial nerves is affected in a patient diagnosed with Bell’s palsy?
Fifth cranial nerve Eleventh cranial nerve Third cranial nerve Ninth cranial nerve Seventh cranial nerve Eighth cranial nerve
Seventh cranial nerve
Which 2 of the following muscles are innervated by the superior division of the third cranial nerve? (Select 2)
Medial rectus Superior rectus Levator palpebrae superioris Mueller's muscle Sphincter pupillae Superior oblique
Superior rectus
Levator palpebrae superioris
The superior division of the third cranial nerve innervates the levator palpebrae superioris and the superior rectus muscles.
The inferior division innervates the medial rectus, inferior rectus, and inferior oblique muscles. The branch that leads to the inferior oblique also contains preganglionic parasympathetic pupillary fibers from the Edinger-Westphal subnucleus, which innervate the pupillary sphincter and ciliary muscle.
Which space in the meninges of the optic nerve is continuous with the space between the brain meninges such that an increase in cerebrospinal fluid pressure may cause the appearance of papilledema?
Dural sinuses
The subdural space
Subarachnoid space
The subpial space
answer is Subarachnoid space = between arachnoid and the pia mater
trauma or sickness the dura and arachnoid may become separated resulting in a space called the subdural space.
Which of the following is LEAST likely to result in the observation of an afferent pupillary defect?
Severe, bilateral, asymmetrical macular degeneration
A dense unilateral cataract
A patient with a dense corneal scar in one eye and glaucomatous damage in the contralateral eye
Asymmetric, bilateral, glaucomatous damage with 20/20 acuity in both eyes
A dense unilateral cataract
Damage to pupillary fibers connecting which of the following structures results in light-near dissociation?
Pretectal nucleus to Edinger-Westphal nucleus
Retina to pretectal nucleus
Edinger-Westphal nucleus to ciliary ganglion
Ciliary ganglion to iris sphincter
Pretectal nucleus to Edinger-Westphal nucleus
The pupillary light reflex begins with the retinal photoreceptors and is composed of four neurons, ending at the iris sphincter. The first neuron connects each retina with both pretectal nuclei that reside in the midbrain in the area of the superior colliculi. Fibers running from the nasal retina decussate at the optic chiasm and pass along the opposite optic tract, reaching the contralateral pretectal nucleus.
Contrastingly, impulses originating at the temporal retina are conducted by fibers that traverse the ipsilateral optic tract, terminating at the ipsilateral pretectal nucleus. The second neuron in this pupillary light reflex connects each pretectal nucleus to both the ipsilateral and contralateral Edinger-Westphal nuclei. It is because of these connections that a light stimulus presented to one eye will evoke a bilateral and symmetrical pupillary constriction. Damage to these neurons (also known as intercalated neurons) is responsible for light near dissociation that is commonly associated with neurosyphilis. The next neuron in this pathway connects the Edinger-Westphal nucleus to the ipsilateral ciliary ganglion, while the final neuron leaves the ciliary ganglion and terminates at the iris sphincter muscle.
Which of the following statements is TRUE in regards to pharmacologic testing in patients with a suspected Horner’s syndrome?
Cocaine and hydroxyamphetamine can be used interchangeably to differentiate between pre and post-ganglionic lesions
Hydroxyamphetamine confirms a diagnosis of Horner’s; cocaine will differentiate between pre and post-ganglionic lesions
Cocaine confirms a diagnosis of Horner’s; hydroxyamphetamine will differentiate between pre and post-ganglionic lesions
Cocaine and hydroxyamphetamine can be used interchangeably to confirm a diagnosis of Horner’s
Cocaine confirms a diagnosis of Horner’s; hydroxyamphetamine will differentiate between pre and post-ganglionic lesions
cocain –> horner will not dilate
1% apraclonidine –>horner dilate
1% phenylephrine –>dilate post ganglion lesion
hydroxyamphetamine –>dilat pre ganglion
Visual acuity can be used to assess the function of which cranial nerve?
III II IV VI VI
CN2
