Board Certified Ophthalmologist FREE Board Certified Ophthalmologist Neuro-Ophthalmology Questions and Answers 2 — Questions and Answers
Question 1: A 45-year-old patient presents with sudden painless monocular vision loss and a relative afferent pupillary defect. Fundoscopy reveals a swollen optic disc with peripapillary hemorrhages. What is the most likely diagnosis?
- Anterior ischemic optic neuropathy (Correct answer)
- Central retinal artery occlusion
- Optic neuritis
- Papilledema
Correct answer: Anterior ischemic optic neuropathy
Sudden painless vision loss with disc swelling and peripapillary hemorrhages in a middle-aged patient is classic for non-arteritic anterior ischemic optic neuropathy (NAION).
Question 2: Which cranial nerve palsy is most commonly associated with microvascular ischemia in a diabetic patient and typically resolves spontaneously within 3 months?
- Cranial nerve III (Correct answer)
- Cranial nerve IV
- Cranial nerve VI
- Cranial nerve VII
Correct answer: Cranial nerve III
Microvascular third nerve palsy in diabetics characteristically spares the pupil and resolves spontaneously within approximately 3 months.
Question 3: A patient with multiple sclerosis develops acute painful vision loss in the left eye with dyschromatopsia. MRI shows enhancement of the left optic nerve. What treatment is recommended to hasten visual recovery?
- Intravenous methylprednisolone (Correct answer)
- Oral prednisone alone
- Plasma exchange as first-line therapy
- Observation only
Correct answer: Intravenous methylprednisolone
The Optic Neuritis Treatment Trial demonstrated that IV methylprednisolone hastens visual recovery in optic neuritis, while oral prednisone alone increased recurrence risk.
Question 4: A 70-year-old woman presents with new-onset diplopia, jaw claudication, and an ESR of 95 mm/hr. What is the most critical next step to prevent permanent vision loss?
- Immediate high-dose systemic corticosteroids (Correct answer)
- Temporal artery biopsy before any treatment
- MRI of the orbits
- Observation with serial visual fields
Correct answer: Immediate high-dose systemic corticosteroids
Giant cell arteritis requires immediate high-dose corticosteroids to prevent irreversible bilateral vision loss; biopsy can be performed after treatment initiation without affecting results for up to two weeks.
Question 5: A patient presents with bilateral optic disc edema, transient visual obscurations, and pulsatile tinnitus. Opening pressure on lumbar puncture is 32 cm H2O. Which visual field defect is most characteristically associated with this condition?
- Enlarged blind spot (Correct answer)
- Central scotoma
- Bitemporal hemianopia
- Homonymous hemianopia
Correct answer: Enlarged blind spot
Idiopathic intracranial hypertension (pseudotumor cerebri) most characteristically causes enlarged blind spots due to papilledema-related expansion of the optic disc.
Question 6: A 30-year-old man presents with a fixed, dilated left pupil, ptosis, and the eye is deviated inferiorly and laterally. CT angiography reveals a posterior communicating artery aneurysm. Which finding distinguishes a compressive third nerve palsy from a microvascular one?
- Pupil involvement (Correct answer)
- Presence of ptosis
- Limitation of adduction
- Pain at onset
Correct answer: Pupil involvement
Pupil involvement (mydriasis) is the key distinguishing feature of compressive third nerve palsy because the parasympathetic pupillary fibers run superficially on the nerve and are compressed first by an aneurysm.
Board Certified Ophthalmologist FREE Board Certified Ophthalmologist Neuro-Ophthalmology Questions and Answers 2
A 45-year-old patient presents with sudden painless monocular vision loss and a relative afferent pupillary defect.
Fundoscopy reveals a swollen optic disc with peripapillary hemorrhages.
What is the most likely diagnosis?