Optic Nerve/ Neuro-ophthalmic Pathways

Question 1

Classic triad of Horner’s

Answer 1

PAM!!! PAM!!!
1. Ptosis (small, affects Muller’s muscle)
2. Anhidrosis (lack of sweat on one side)
3. Miosis (pupil constriction)

Question 2

Argyll Robertson pupil associated with what infectious disease?

Answer 2

Late-stage syphilis

Question 3

Physiological anisocoria

Answer 3

• Anisocoria equal under dim and bright conditions
• no ptosis
• confirm stability by referring to previous photos of patient

Question 4

Signs of pupil involving 3rd nerve palsy

Answer 4

Eye is down and out with dilated (blown out) pupil

Question 5

Patient presents with diplopia, headache, eye is down and out with a blown out pupil, what is your A&P?

Answer 5

A. Pupil involving cranial nerve 3 palsy caused by aneurysm of the posterior communicating artery
P. Send to emergency room ASAP (EMERGENT!!!)

Question 6

Congenital Horner’s syndrome signs

Answer 6

Iris heterochromia (affected eye will have lighter iris)

Question 7

Characteristics of tilted disc syndrome

Answer 7

• Bilateral
• optic nerve enters at an oblique angle superiorly
• situs inversus

Question 8

Signs of tilted disc syndrome

Answer 8

• myopic
• fundus ectasia
• superior temporal VF defects that do not respect the midline

Question 9

A&P for Horner’s

Answer 9

A. Horner syndrome
1. isolated damage of 3rd order neuron
2. pre-ganglionic lesion

Plan
1. No further investigation
2. Refer for MRI of head and neck and a CT scan of thorax or chest x-ray (pancoast tumor)

Question 10

Right homonymous hemianopia is associated with stroke on which side of the brain? And can cause hemiparesis on which side of the body?

Answer 10

Cerebrovascular accident on left side of brain and patient likely has hemiparesis on right side of their body

Question 11

Pulfrich phenomenon

Answer 11

Pendulum is perceived as moving in a circular motion rather than laterally
* symptom of optic neuritis

Question 12

Ocular manifestation of multiple sclerosis

Answer 12

Optic neuritis

Question 13

Optic neuritis age demographic

Answer 13

18 to 45 years old

Question 14

Uhthoff sign

Answer 14

Associated with MS

Symptoms worsen with increase in body temperature

Question 15

True or false
Horner’s syndrome can be caused by internal carotid artery dissection

Answer 15

TRUE
* 3rd order neuron damage from internal carotid artery dissection can cause Horner’s syndrome

Question 16

Patients suspected with Horner’s due to a pre-ganglionic lesion should be referred for what further testing?

Answer 16

• MRI of head and neck
• CT scan of thorax
• chest x-ray (check for pancoast tumor)

Question 17

Parietal lobe lesion will produce what VF loss?

Answer 17

Inferior incongruous or congruous VF loss (quadrantanopia)
* pie on the floor (parents put you down lesion in parietal lobe)

Question 18

Lesion in temporal lobe produces what VF loss?

Answer 18

Superior quadrant VF defect, incongruous and wedge shaped, can also be complete
* superior quadrantanopia = pie in the sky

Question 19

Optic radiations traveling through ____ lobe carry visual information from the superior retina

Answer 19

Parietal lobe
* VF loss will be opposite therefore superior retina damage will cause inferior VF loss

Question 20

3rd order neuron irregularities can be caused by?

Answer 20

Cluster headaches
Otitis media
Masses in cavernous sinus
Internal artery dissections
Nasopharyngeal tumors

Question 21

Pancoast tumor can cause which order neuron irregularity in Horner’s?

Answer 21

2nd order neuron lesion

Question 22

What is the most common cause of pupil sparing isolated 3rd nerve palsy?

Answer 22

Microvascular disease secondary to HTN &/or diabetes

Question 23

Blood supply to oculomotor nerve

Answer 23

Surface and pupillary fibers are supplied by pial blood vessels; internal fibers are supplied by the vasa nervorum

Question 24

What are the common triggers of a classic migraine?

Answer 24

• stress
• coffee
• chocolate
• cheese
• prolonged periods without food
• bright lights
• alcohol
• severe fatigue
• birth control

Question 25

Visual aura of a classic migraine would produce what type of visual field defect?

Answer 25

Homonymous hemianopsia
* start in center and enlarge in homonymous portions of the visual field
* HA located on contralateral side of field defect

Question 26

Leber hereditary optic neuropathy is more common in males or females?

Answer 26

males

Question 27

What is Tilted Disc Syndrome?

Answer 27

A condition where the optic nerve enters the eye at an oblique angle, causing elevation of superior nerve tissue and ectasia of inferior/infero-nasal tissue

Typically observed bilaterally.

Question 28

What visual field defects are often associated with Tilted Disc Syndrome?

Answer 28

Superotemporal defects

These defects may diminish or disappear with myopic astigmatism correction.

Question 29

What are common symptoms of Tilted Disc Syndrome?

Answer 29

Majority are asymptomatic; some may report visual field defects or blurred vision

Symptoms can be caused by uncorrected astigmatism.

Question 30

What clinical signs indicate Tilted Disc Syndrome?

Answer 30

• Obliquely inserted disc
• Myopic astigmatism
• Tilted optic disc with inferior ectasia
• Superior elevation of nerve tissue
• Situs inversus
• Fundus ectasia
• Superotemporal visual field defects

Visual field defects generally do not respect the midline.

Question 31

What is the treatment for Tilted Disc Syndrome?

Answer 31

Visual correction to neutralize the associated refractive component

No additional treatment is required.

Question 32

How often should patients with Tilted Disc Syndrome be evaluated?

Answer 32

Annually

Regular follow-up helps monitor any changes.

Question 33

Fill in the blank: Tilted Disc Syndrome is caused by an optic nerve that enters the eye _______.

Answer 33

[superiorly at an oblique angle]

Question 34

VF defects of tilted disc syndrome similar to what type of tumor VF defect?

Answer 34

Pituitary gland tumor —> bitemporal field defect
* neuroimaging required to establish concrete diagnosis