ABO Neuro-Ophthalmology 2 — Questions and Answers
Question 1: A 52-year-old presents with acute headache, ptosis, and a dilated, poorly reactive left pupil with limited adduction and elevation. What is the most appropriate next step?
- Observation and recheck in 3 months
- Urgent CT angiography or MR angiography (Correct answer)
- Check hemoglobin A1c and start aspirin
- Ice pack test
Correct answer: Urgent CT angiography or MR angiography
Pupil-involving third nerve palsy with headache suggests a posterior communicating artery aneurysm requiring urgent vascular imaging.
Question 2: In a patient with suspected Horner syndrome, topical apraclonidine 0.5% typically produces which result?
- Constriction of the affected pupil
- No change in either pupil
- Dilation of the affected pupil and elevation of the ptotic lid (Correct answer)
- Dilation of the normal pupil only
Correct answer: Dilation of the affected pupil and elevation of the ptotic lid
Denervation supersensitivity of alpha-1 receptors causes the Horner pupil to dilate and the lid to rise, reversing anisocoria.
Question 3: A young woman has a unilaterally dilated pupil with poor light reaction, slow tonic near response, and sectoral iris paralysis. Which test supports the diagnosis?
- Constriction with dilute pilocarpine 0.125% (Correct answer)
- Dilation with 10% cocaine
- No response to 1% pilocarpine
- Dilation with hydroxyamphetamine 1%
Correct answer: Constriction with dilute pilocarpine 0.125%
Adie tonic pupil shows cholinergic denervation supersensitivity and constricts to dilute pilocarpine.
Question 4: According to the Idiopathic Intracranial Hypertension Treatment Trial, which intervention combined with weight loss improved visual field outcomes in mild visual loss?
- Topiramate
- Optic nerve sheath fenestration
- Furosemide
- Acetazolamide (Correct answer)
Correct answer: Acetazolamide
IIHTT showed acetazolamide plus diet improved perimetric mean deviation versus diet alone.
Question 5: A patient has a right hypertropia that worsens on left gaze and on right head tilt. Which muscle is paretic?
- Left superior oblique
- Right inferior rectus
- Right superior oblique (Correct answer)
- Left inferior oblique
Correct answer: Right superior oblique
The Parks-Bielschowsky three-step test localizes this pattern to a right superior oblique (fourth nerve) palsy.
Question 6: A 28-year-old with multiple sclerosis cannot adduct the right eye on left gaze, and the left eye shows abducting nystagmus; convergence is intact. Where is the lesion?
- Left abducens nucleus
- Right medial longitudinal fasciculus (Correct answer)
- Left paramedian pontine reticular formation
- Right oculomotor nucleus
Correct answer: Right medial longitudinal fasciculus
Internuclear ophthalmoplegia is named for the side of the adduction deficit, localizing to the ipsilateral MLF.
Question 7: Which finding came from the Optic Neuritis Treatment Trial?
- Oral prednisone alone increased the risk of recurrent optic neuritis (Correct answer)
- IV methylprednisolone improved final visual acuity at 1 year
- Most patients had permanent vision worse than 20/200
- Brain MRI did not predict multiple sclerosis risk
Correct answer: Oral prednisone alone increased the risk of recurrent optic neuritis
Standard-dose oral prednisone alone was associated with a higher recurrence rate and is not recommended.
ABO Neuro-Ophthalmology 2
A 52-year-old presents with acute headache, ptosis, and a dilated, poorly reactive left pupil with limited adduction and elevation.
What is the most appropriate next step?