Papilledema and Pupillary Disorders (F)

Question 1

What does a Horner syndrome patient with facial anhydrosis indicate?

Answer 1

lesion between posterior hypothalamus and carotid bifurcation (first order)

Question 2

What is the treatment for idiopathic intracranial hypertension with with severe or progressive visual loss?

Answer 2

1. optic nerve sheath decompression
2. high dose steroids and acetazolamide
3. lumbo-peritoneal shunt for failed ONSD or intractable headache

Question 3

What are some pharmacologic agents that can result in pupillary dilation?

Answer 3

1. scopolamine or permethrin
2. angels trumpet, jimson weed, or belladonna
3. antihistamines

Question 4

What is the result of an interruption between mesencephalon and sphincter?

Answer 4

pupillary dilation and decreased speed and amplitude of constriction (EPD)

Question 5

What is the result of an interruption between retinal ganglion cells and pretectal nuclei?

Answer 5

APD

Question 6

What are factors associated with higher risk of visual loss for patients with idiopathic intracranial hypertension?

Answer 6

1. systemic hypertension
2. anemia
3. peripapillary subretinal neovascularization
4. older age
5. high myopia

Question 7

What does hydroxyamphetamine help to indicate in Horner Syndrome and how?

Answer 7

dilation indicates first or second order lesion due to cause of NE release from normal post-ganglionic neuron

Question 8

What are possible etiologies of Horner syndrome second order neuron lesions?

Answer 8

1. chest lesions (occult carcinoma of lung apex, mediastinal mass)
2. neck lesions (trauma, abscess, thyroid neoplasm, internal carotid dissection, lymphadenopathy)
3. surgery (thyroidectomy, radical neck surgery, carotid angiography

Question 9

What is the treatment for idiopathic intracranial hypertension with no vision loss?

Answer 9

1. symptomatic headache therapy
2. weight reduction
3. acetazolamide

Question 10

What is an increase in intracranial pressure with one swollen disc and one atrophic disc called?

Answer 10

Foster Kennedy Syndrome

Question 11

What does phenylephrine help to indicate in Horner Syndrome and how?

Answer 11

dilation or greater relative dilation suggests post-ganglionic lesions (third order) due to denervation hypersensitivity

Question 12

Why do lesions at the LGN, optic radiations, and visual cortex not generally result in afferent pupillary defects?

Answer 12

afferent pupillary fibers leave the optic tract before the LGN

Question 13

Where does the pre-ganglionic (second order) neuron of the oculosympathetic pathway arise? 1. Where does it synapse? 2

Answer 13

1. ciliospinal center of Budge (under subclavian artery, over lung apex, and ascends with internal carotid)
2. superior cervical ganglion (plexus on internal carotid artery)

Question 14

When are headaches associated with idiopathic intracranial hypertension worse?

Answer 14

1. mornings

2. postural changes or Valsalva maneuvers

Question 15

What is the treatment for idiopathic intracranial hypertension with mild visual loss?

Answer 15

1. acetazolamide
2. furosemide
3. weight reduction

Question 16

What is the parasympathetic efferent pathway to the pupil?

Answer 16

1. efferent originate at Edinger-Westphal complex
2. Fibers exit the midbrain in third cranial nerve and follow inferior division in cavernous sinus to orbit
3. fiber synapse at ciliary ganglion in posterior orbit, btw optic nerve and LR
4. postganglionic fibers travel in short ciliary nerves to globe then btw sclera and choroid to sphincter and CB

Question 17

If there is the same amount of anisocoria in the light as in the dark, what is the likely cause?

Answer 17

physiologic anisocoria

Question 18

Where does the central (first order) neuron of the oculosympathetic pathway arise? 1. Where does it synapse? 2

Answer 18

1. hypothalamus

2. ciliospinal center of Budge (T1-C8)

Question 19

What is the pathway of the post-ganglionic (third order) neuron of the oculosympathetic pathway arise? 1. Where does it synapse? 2

Answer 19

1. superior cervical ganglion, travel along internal carotid into cavernous sinus, then VI cranial nerve, then nasociliary nerve (V1), then the long ciliary nerve in to the orbit
2. dilator muscle