1. You examine 7 yo boy who presents with
    best corrected VA’s of 20/40 OU. Pupils, eoms and VF are normal
    OU. Color vision is 10/14 OU. Perform OKN and nontice normal
    response when drum is rotated to right and left. Rest of exam is
    normal OU. Pupillary evaluation shows anisocoria of 1.5mm OD being
    the larger pupil. The anisocoria is greater in dark you expose the
    pupils to bright light then immediately to darkness and after 5
    seconds in dark both pupils have original darkness full diameter.
    Rest of external and internal exam is normal. You next best approach
    should be:

    a. order an MRI
    b. refer for psychological counseling
    c. follow carefully and repeat
    pupillary evaluation and VF’s 5-7 days
    d. order an ERG
    e. do paredrine and apraclonidine

    think Horners but it is normal dilation lag, therefore physiological pupil.

    Order ERG for a color dystrophy.  If horners then you would do an MRI
  2. A patient complains about gradual loss
    of vision OD. Exam shows a right Horner’s syndrome, decreased
    corneal sensation OD, right CN IV palsy and right +2 RAPD. Best
    corrected VA’s are 20/50 OD and 20/20 OS. Color vision is 3/14 OD
    and 14/14 OS. Most probable site of lesion is:
    a. cavernous sinus
    pontomesencephalic junction pre-decussation fourth n. fibers
    c. orbital apex
    d. superior orbital
    pontomesencephalic junction post decussation fourth n. fibers

    For the patient describe above,
    expected pupillary testing results will be:
    a. 4% cocaine
    b. phenylephrine
    will dilate OD, will not dilate OS.
    d. apraclonidine 1% might dilate OD
    and OS.
    • C.
    • No RAPD with cavernous sinus. 
    • decreased VA and cv.  So this is optic nerve head involvement. 
    • Decrease in corneal sensation means V1 which only goes thru the SOF so it is between the SOF and orbital apex.

    Dx. Horner's (3rd order)

  3. A patient has a right inferior
    oblique palsy. Compensatory head posture for this patient will be:

    A. Left head turn, chin up, left head
    B. Right head turn, chin up, left
    head tilt
    C. Right head turn, chin down, right
    head tilt
    D. Left head turn, chin down, right
    head tilt
    E. Left head turn, chin up, right
    head tilt
  4. You are performing EOMS on a 40 y/o
    female patient and notice that when the right eye adducts, the right
    lid retracts. Rest of exam is normal. You go back to the history,
    but she denies prior episodes of ocular trauma, Hx of medical
    disease, surgery or diplopia. Your best NEXT approach would be:
    a. order CT scan
    b. order thyroid profile: TSH, T3 and
    c. refer to neurologist to RO
    Parinauds syndrome
    d. perform manual occlusion test to
    r/o ptosis of left eye
    e. ask for old photos and f/u
    carefully every 1 month.
    • A.
    • Dx. Aberrand degeneration Primary
  5. The Rinne test is important for the evaluation of what nerve?

  6. A patient has a sudden onset of
    excruciating right hemicranial HA and photophobia. Ct scan shown
    aneurysm of post communicating artery. Which VF most likely:

    For the patient described above,
    which will be the EXPECTED papillary pharmacological testing

    Instilling 1% pilocarpine OD
    will constrict the pupil
    Instilling 1% pilocarpine OD will
    not constrict the pupil
    Instilling 0.1% pilocarpine OD
    will constrict the pupil
    Instilling 0.125% pilocarpine will
    constrict the pupil
  7. A patient w/ Hx of hypercholesteremia
    has transient weakness of left side of the body. Cerebral
    circulation studies show right internal carotid artery occlusion of
    40% in its cervical segment. BEST treatment for this patient should
    a. external carotid by pass surgery
    b. endarterectomy
    c. aspirin 325 mg
    d. tight control of cholesterol levels with lipid lowering agents
    e. anti hypertensive agents
  8. A patient has headaches with visual fields defects. CT scan shows
    left posterior optic tract disease in late stages. Which of the
    following would be a FALSE statement?

    a. Patient has right ONH pallor on nasal and temporal quadrants
    b. Patient has a + RAPD on eye that shows a nasal field loss on VF testing
    c. Patient most probably has normal VA’s both eyes
    d. Lesion could affect the cerebral penduncles as it progresses
    e. Demyelinating disease should be ruled out

    • A lesion of the anterior OT will give you an ipsilateral/nasal defect RAPD
    • A lesion of the POSTERIOR OT will give you a contralateral/temporal defect RAPD
  9. 79 y.o. female patient has a high
    right lid crease as compared to the left eye. Marginal reflex
    distance (MRD) is of 1 mm OD and 4 mm OS. Levator functions is 12 mm
    OD and 13 OS. Pupils are PERRLA OU and rest of exam is normal. MOST
    PROBABLE diagnosis is:

    a. involutional ptosis
    b. congenital ptosis
    c. myasthenia gravis
    d. neurogenic ptosis
  10. What would the visual field defects of an anterior cerebral artery with resultant VF defect look like?
    Superior slightly bitemporal wedge shaped defects
  11. What arteries supply the chiasm?
    • Superiorly the Anterior Cerebral Artery
    • Inferiorly the Superior Hypophyseal Artery
  12. An 18 y/o male had trauma few days ago
    and developed vertical diplopia. No other signs or symptoms. Your
    evaluation reveals right hypertropia which increases in left gaze and
    left hypertropia which increases in right gaze. MOST probable site
    of lesion causing this case scenario IS:

    A. area of fourth ventricle
    B. pontomesenphalic junction
    C. tentorial edge
    D. anterior medullary vellum
    E. posterior commisure

    What muscle is affected?

    For the patient described above,
    which of the following statements is CORRECT?

    A. On Trial frame Maddox test, patient will have excyclorotation of OD and OS
    B. Patient’s vertical amplitudes should measure from 13-14 prism diopters
    C. It is expected to find a +APD on right eye
    D. On fundus check, macula OD looks “below ONH”; macula OS is “above ONH”
    E. Patient should have a cocaine oph soln test

    Bilateral Superior oblique

  13. A patient shows paralysis of all
    muscles of the left side of FACE, loss of pain and thermal sensation
    of the left side of face and loss of pain and thermal sensation of
    the right side of body. Where is the most probable side of lesion?

    a. right cerebral cortex
    b. right lateral caudal pons
    c. left lateral caudal pons
    d. left medial pons
    e. right medial pons.
  14. A 25 y/o healthy female awoke with a
    fixed and dilating pupil OD. She denies HA, no trauma, no neuron
    signs. Only fact she gives is having being in bed with a cold few
    days ago but now she feels fine. She is not taking medications and
    has NKA. Your exam is only accommodation. Rest of exam in normal
    OU. Institlling 0.1% pilocarpine does not constrict OD or OS.
    Instilling 1% pilocarpine constrict both pupils. Your order STAT
    neuron evaluation and it comes up normal; neuroimaging shows no
    abnormalities. What now should be your best approach for this
    a. counsel her and f/u in 1 yr
    b. have her back
    in 6-8 weeks and repeat the 0.1% pilo test

    c. prescribe
    reading glasses and see her 6-8 months
    d. fu in one week
    and perform diplopia work up
    e. order vascular
    work up

    • In Adies the regeneration of the fibers
    • takes about 8 weeks. That’s why she is not responding to 0.1%
    • pilo. So repeat the test. This is an EARLY Adie’s. It is not yet
    • hypersensitive to Pilo.
  15. A patient has an inferior
    division CN III palsy of the left eye and right side arm tremors.
    This patient shows:

    A. A nuclear CN III involvement
    B. A superior orbital fissure CN III involvement
    C. A subarachnoid CN III involvement
    D. An interpeduncular fossa route CN III involvement
    E. A fascicular CN III involvement
  16. A 70 y/o male has loss of corneal
    reflex OD. + Romberg test on right side, loss of gag reflex, voice
    hoarseness and he also shows a right Horner’s syndrome. You
    proceed to perform pharmacol pupillary testing. Taking in
    consideration the pts clinical picture and your tentative diagnosis,
    which of the following will be expected pupillary testing response?
    a. 4% cocaine will
    not dilate OD, will dilate OS. 1% paredrine willd ialte OD, will not
    dilate OS
    b. paredinre will
    not dilate OD, will dilate OS
    c. 4% cocaine
    will partially dilate OD, will dilate OS.
    d. phenylephrine 1%
    will dilate OD, will have no effect on OS

    The most probable lesion
    for the case described above is:

    A. Occlusion of the Right Posterior Choroidal artery
    B. Occlusion of the Right Top of Basilar artery
    C. Occlusion of the Right Posterior Inferior Cerebellar artery
    D. Occlusion of the Right Anterior Inferior Cerebellar artery
    E. Occlusion of the Right Superior Cerebellar artery

    Central Horner's  or Wallemberg.  C or A.

    • C.
    • Wallemberg is PICA--> horner's + gait test (romberg) and central lesion
  17. An 80 y/o patient complaints of when he
    goes outside in very bright light he experience darkening of vision
    OD and it takes about 20 mins for it to return to normal again (TIA).
    He also complains of smaller eye OD since few months ago. Exam shows
    an MRD of 2mm OD and 5mm OS, and aniscoria with OD smaller than OS
    more prominent in dim illumination. Levator function is normal.
    Retinal exam shown blot and dot hemes around the vortex veins in OD,
    OS is normal (venous statis retinopathy). MHx is + HBP and
    arthritis. Based on the above ex
    a. apraclonidine
    will have effect on OD, no effect on OS*
    b. phenylephrine
    has no effect on either pupil
    c. 0.1% pilocarpine
    has no effect on OD, has an effect on OS
    d. 4% Cocaine has
    an effect on both OD and OS
    e. No Need for
    Pharmological testing

    • This is a carotid problem and it is associated with CN III Horner's
    • OS is normal, no effect there
  18. A patient has left side decreased
    lacrimation and salivation. Rest of exam is normal. The MOST
    PROBABLE anatomical site affected is:

    A. geniculate ganglion
    B. nervus intermedius
    C. inferior salivatory nucleus
    D. exit side of internal auditory meatus
  19. A 60 y/o male complains of loss of
    vision OD which he noticed upon awakening a few days ago. He has no
    other symptoms or complaints. VAs are 20/50 OD and 20/20 OS. Color
    vision is 2/10 OD and 10/10 OS. + APD OD. IOPs are 12mmHg OU with
    normal pachymetry. MHx is negative but he has had no physical exam
    in many years. STAT ESR is 20 mm/hr. What is your diagnoses?
    VF OD shows: monocular altitudinal VF
    OS is normal.
    a. HTN
    b. DM
    c. temporal
    d. cardiovascular
    e. cerebrovascular

    • Notes: Think more of the Optic Nerve
    • Head. What constitutes a VF of an Inferior altitudinal?
    • AION or NAION
    • To calculate ESR
    • Male = Age/2
    • Female = Age + 10 / 2

    This is an ischemic problem.

    • HTN is 35%
    • DM is 10-25%
    • Also, look for SMALL CROWDED DISC
    •  these are related to NAION
  20. A 45 y/o man complains to his family
    physician that there seems to be something wrong with his mouth. The
    examination reveals of the mastication muscles, a deviation of the
    jaw to the left on closure, and a loss of all sensation on the same
    side of the jaw. MRI shows a compressing tumor. Compression of which
    of the following structures would most likely be the cause of the
    deficits experienced by this man?
    a. maxillary nerve on the left
    b. mandibular
    nerve on the left
    c. mandibular nerve
    on the right
    d. maxillary nerve
    on the right
    e. right
    hypoglossal nerve
  21. A patient has a right CN III
    palsy. CT Scan shows a lesion at the level of the crus cerebri.
    You would expect this palsy to be accompanied by:

    A. left side tremors
    B. right side ataxia
    C. right side decreased face touch and temperature sensation
    D. left side hemiplegia
    E. right side ataxia and left side tremors (Claude’s Sign)
  22. A 35 y/o female has progressive loss of
    vision OD for the last months. Today she woke up seeing double. Your
    exam shows BCVA 20/50 OD and 20/20 OS. Pupils fixed and dilated OD.
    On evaluation pupillary reflexes, OD does not react to light and in
    OS the consensual response is weaker that the direct one. Evaluation
    of the muscles shows an IR, MR and IO deficit OD. Lids are normal
    OU. The most probable site of the lesion is:
    a. sphenocavernous
    b. ciliary ganglion
    c. superior
    d. ventral midbrain
    e. orbital apex

    • There is an RAPD in OD. CN 3 problem
    • because of the EOMs palsy.
  23. A patient has right side total
    facial and neck motor weakness with intact salivation. Most
    probable condition to be ruled out in this patient should be:

    A. Nasopharyngeal carcinoma
    B. Mastoiditis
    C. Herpes Zoster
    D. Labyrinthe disease
    E. Cerebellopontine angle disease

    It is a total facial palsy, not partial so you know it is #6 on the CN VII diagram
  24. A Pt is fixating on a central target
    with his head straight. You rotated a Pts head to the left in the
    horizontal plane and see no movement of either eye; and he losses
    fixation of target (dolls eye). When you rotate the Pt’s head to
    the right the patient’s eyes move so they keep fixation on the
    target. All the following are true statements. EXCEPT:

    a. a lesion on the
    left ampulla
    b. left medullary
    c. a lesion in the
    right MLF
    d. a lesion on
    right PPRF
    e. patient has
    involvement of the VIII nerve
    • c.
    • Bad Doll's head means it is infranucular lesion
  25. Patient comes in with no other problems other than a left hemianopsia with macular sparing OU.
    Which of the following is the MOST
    correct statement?

    A. Patient has a deep parietal lobe lesion
    B. Patient has a purely striate occipital lobe lesion
    C. Patient has a striate and extrastriate occipital lobe lesion
    D. Patient has an occlusion of PCA and MCA
    E. Patient has head injury to occipital lobe most posterior segment
  26. A pt has complete CN III palsy on OD
    and ptosis and SR deficit on OS. This is MOST compatible with a:

    a. fascicular CN
    III lesion
    subarachnoid CN III lesion
    cavernous sinus CN III lesion
    superior orbital CN III lesion
    e. Nuclear CN
    III lesion

    Complete CN III palsies are Nuclear
  27. A 49 patient has a unilateral CN
    IV palsy; rest of exam is normal. You suspect a longstanding palsy
    and not a recently acquired one. The BEST finding that will
    confirm that indeed this is a longstanding CN IV palsy would be:

    A. patient has a head tilt to the opposite shoulder
    B. large vertical fusional vergences
    C. patient has minimal excyclorotation on Maddox rod
    D. the Park 3 step Method does not work
    E. patient has no other company signs

    Large vertical fusional vergeces pertain to longstanding cases
  28. A patient has a supranuclear conjugate
    eye movement dysfunction and the following VF defect: left hemianopsia OU. Which of the following would be incorrect?

    direction of the conjugate eye movement deficit

    Lesion of the Right POF, right gaze palsy and eyes will deviate to the left
  29. A patient has right lower neuron
    CN VII palsy and hearing loss. Which of the following staments
    should be INCORRECT?

    A. lesion is in the fallopian canal just above the stapedius muscle nerve take off
    B. patient could show unilateral keratitis
    C. patient could have sublingual and submandibular salivary glands hyposecretion
    D. patient could have loss of sensation of external ear
    E. patient could have vertigo

  30. a pt shows severe ptosis of OD. Upon
    raising the lid you notice OD can not adduct, elevate or depress; it
    can abduct. Pupillary evaluation shows the right pupil is larger
    than OS in bright light and smaller that OS in dim light. These
    clinical signs MOST probably localizes the lesion to:
    a. midbrain
    b. cavernous
    c. brachium of
    superior colliculi
    d. orbit
    e. uncus

    Anisocoria and fixed dilated pupil.  You will have both efferent and afferent problems.  Along with CNIII problem you will find this in the Cavernous sinus.
  31. A patient has total left side
    facial weakness. On doing EOM’s you notice absent conjugate
    movement to the left. You ask the patient to close his eyes and
    hold the hands out in front w/ palms facing up. After a few
    seconds you notice right hand falls downward. The MOST PROBABLE
    anatomic site of lesion is:

    A. left corticobulbar tract
    B. left facial colliculi
    D. left lateral mesencephalon
    E. left pontine pyramidal tracts
    F. right medial pons

    There are absent conjugate movements to the left which is saying there is EOM palsy.  This is a motor defect which is in the pyramidal tracts.  Millardy Gubard syndrome
  32. A 32 y.o. female patient with
    negative medical history has a fixed dilated pupil OD. Instilling
    0.1% pilo constricts OD, but not OS. Which of the following tests
    should be performed in this patient?

    A. Tendon reflexes
    B. VDRL
    C. indirect afferent pupillary
    D. FBS
    E. Romberg Test

    • You want to test for syphilis to R/O
    • your DDx for the syphilis associated pathologies. But with Adies you
    • will also have a decreased tendon reflex
    • Answer: A and B.
  33. A patient has a recent right
    complete CN III palsy from cavernous sinus lesion. Neuroimaging
    studies report that the intracavernous fourth nerve fibers are not
    compressed or involved. Which of the following is a TRUE statement
    regarding the above mentioned case scenario?

    A. When you ask the patient to look to the left, the right macula moves down
    B. Park 3 Step will be the best diagnostic test to screen for presence of SO palsy in the above case scenario (only works with only 1 muscle involved)
    C. If the patient were to have a paralysis of the right CN IV, you will be able to see overaction of the RIO when you ask the patient to look in the field of action of the RSO
    D. If you ask the patient to look down, you should be able to see upward movement of a right temporal
    conjunctival vessel
    E. Patient afferent system should be affected
  34. A pt has Vas 20/20 OU. Exam shows a
    right SO palsy, right horners syndrome and left APD. Rest of ocular
    exam is normal. What is the MOST probable explanation of this case
    a. right midbrain lesion
    compressing left CN 4 post decussating fibers
    b. left
    pontomesenphalic junction lesion compressing pre decussating left CN
    4 fibers
    c. right
    pontomesenphalic right CN 4 nuclear lesion
    d. orbital apex
    lesion – you need chemosis, proptosis, ciliary injection
    e. posterior

    Drow out the CN 4 pathway.  What is the best test for this patient?  Pupils.
  35. Where can you have both afferent and efferent defects?
    Orbital apex in the intraorbital region of OHN

    Cavernous Sinus

    Parietal Lobe

    Aneurysm in the posterior communicating artery

    Large pituitary gland masses that affect the CS

    Pontomesenphalic junction
  36. how long will vision loss occur with carotid artery disease?
    10-20 mins and it will be unilateral
  37. How long will vision loss last if it is  due to vertebral vasilar disease?
    5-10 mins  will be bilateral
  38. how long will vision loss last with papilledema?
    A few seconds.  Bilateral
  39. How long will vision loss last with ION?
    Unilateral for hours and in the morning
  40. What afferent system disorders can cause vision loss in the young?
    • Migraine
    • Optic neuritis
    • papillophlebitis
    • LHON
    • ONH glioma (1 and 2 decade)
    • Dominant optic atrophy (1st decade)
  41. What afferent system disorders can cause TVL in the elderly?
    • Vascular dz
    • GCA
    • Ischemic optic neuropathy
    • * NAION 50yrs
    • * AAION 70 yrs
  42. What afferent system disorders are more common in males?
    • Optic nerve hypoplasia
    • Papillophelbitis
    • LHON
  43. What afferent system disorders are more common in women?
    • Morning glory syndrome
    • Optic neuritis
    • Pseudotumor cerebri
    • AAION
    • ON sheath meningiomas
  44. What afferent disorder can cause a monocular altitudinal defect?
    AION inferior
  45. What afferent system disorder can cause binocular altitudinal defects?
    • Occipital lobe dz
    • topless disk syndrome
    • glaucoma
  46. What afferent diseases do not respect the vertical midline?
    • Glaucoma
    • Auadratic ONH lesions
    • tilted discs
    • nutritional or toxic neuropathies
  47. What afferent defects do not respect the horizontal meridian?
    Neurological dx
  48. Bow tie pallor can be caused by what?
    • Chiasm lesions
    • OT lesions
  49. Telangiectatic vessels are found in what?
    • Diabetic papillopathy
    • LHON
  50. Pulsating tinnitus is found in what afferent disease?
    Pseudotumor cerebri.
  51. Anton's syndrome
    Patient denies blindness due to damage to adjacent extrastriate areas.  Interpretation and recognition of visual images

    Found in Occipital lobe lec
  52. Riddoch Pehnomenon
    Patiet recuperating from occipital lobe injury first starts perceiving moving objects but not stationary ones.
  53. Cogan's dictum
    Homonymous hemianopsia + asymmetrick OKN is probably a parietal lobe lesion due to a mass

    Homonymous hemianopsia + symmetrick OKN means it is probably an occipital lobe lesion of vascular origin.
  54. Lesion of the ONH will show?
    • Monocular VA with APD
    • CV defect
    • VF defect (monocular)
  55. Retrobulbar lesions will show what?
    • Monocular VA Loss
    • CV defect
    • Patient sees nothing
    • ONH looks good
    • VF
    • Central scotoma
    • Cecocenter

    Other Eye is normal
  56. Intracranial ONH lesion will show?
    • Everything in RB ONH
    • + a junctional effect
    • becauseit’s near the chiasm
    • inferior nasal aspectof the
    • other eye(Knee of Willebrand)

    • Gives you a Superior
    • Temporaldefect in other eye and a centralscotoma or
    • cecocenter in that eye.
  57. A lesion in the optic chiasm will show what?
  58. Compresses the ONH
    • Decrease in VA
    • Decrease in CV
    • + RAPD on the opposite side of
    • thelesion
    • + Red Cap/Bright Light Saturation
    • Test
    • VF: Bilateral homonymous
    • hemianopsia
  59. A lesion in the optic tract will show what?
  60. Contralateral + RAPD
    • There are 53 to 47 more nasal
    • fibers than temporal fibers
    • Decrease in VA
    • Decrease in CV
    • Bilateral homonymous hemianopsias
  61. A lesion in the LGN will show what?
  62. VA symptoms
    • NO Pupillary defect
    • NO CV loss
    • NO VA loss
    • VF defect
    • Hemianoptic
  63. A lesion in the midbrain pretectum will show what?
  64. Contralateral + RAPD
    • enourmous swingingflash
    • light test

    • VA normal
    • CV normal
    • VF normal
  65. An occipital lobe lesion will show what?
  66. Normal VA
    • Normal CV
    • Normal Pupils
    • VF
    • Bilateral mirror images
  67. Optic neuropathy will show what?
  68. Papillomacular bundle
    • * Central
    • * Centroceccal
    • * Paracentral
    • * Diffuse
    • * Altitudinal

    • Normal VA 
    • Mild Loss
    • Poor CV
    • + RAPD
    • + Red/Brightness Saturation test
    • Pallor >>> Cupping
  69. Optic Nerve Hypoplasia
  70. Young mother, IDDM,alcohol,
    • drugs
    • Double ring sign
    • De morsier Syndrome
    • Hemihypoplasia “topless”disc
    • syndrome
    • Inferior Alt. VF

    • VF: Altitudinal field loss
    • Approach
    • Children: MRI
    • Adults: None
  71. Tilted Disc
  72. VF: bitemporal field lossnot
    • respecting the verticalmeridian
    • Commonly in myopes
    • Situs invertus: OD looks like OS
    • Approach: NONE
  73. Drusen of the ONH
  74. Bilateral
    • No cup
    • VA good
    • No RAPD, unless severe
    • VF: Arcuate defects
    • Autofluorescence with red
    • free filter
  75. Congenitally Full Disc
  76. Crowded disc
    • Overflow with axonal tissue
    • Assoc. with hyperopes
    • VF: not altered
    • Approach: risk of AION
  77. Myelinated Nerve Fibers
  78. 17-20% bilateral
    • NO va Loss
    • Associated with GORLINSyndrome
    • (Multiple basalnevi)
    • VF: isolated Scotomas ifhigh
    • # of myelinated fibers
  79. Excavated disc
  80. Unilateral OR bilateral
    • Abnormal closure of proximal
    • embryonicfissure
    • Decreased VA on Severity
    • RAPD if unilateral
    • Approach: None
  81. Optic pits
  82. Unilateral
    • Round, dark depression
    • inferotemporal
    • CSR can occur, F/U well
  83. Morning glory syndrome
  84. Funnel like
    • excavationincorporating ONH
    • White tuft of glial tissue
    • Blood vessels (high number)exit
    • in straight course
    • In Child: Must R/OTransphenoidal
    • basalmeningiocele
    • Common in females
    • Approach: MRI
  85. Megalopapilla
  86. Abnormally large disc
    • Bilateral
    • More horizontally elongated
    • Dist. From glaucoma

    • VA normal
    • VF: Enlarged Blind Spot
    • Approach: R/O Glaucoma
  87. Pailledema
  88. Bilateral swelling
    • Paton’s lines
    • Chronic: Champagne-cork
    • Peripapillary Hems
    • Loss of VP
    • Choroidal folds
    • VF: Big Blind Spot orinferonasal
    • defect  central
    • VA is good until late chronic
    • VI N palsy
    • Approach:
    • Emergency!
    • R/O mass, PTC
    • MRI/CT
    • Lumbar Puncture
    • R/O Meningitis

    • NOTE: can have
    • unilateralpapilledema
    • Foster Kennedy Syndrome!!
    • LE – Dead eye
    • RE – Papilledema
  89. NAION
  90. Feels good
    • Vascular insufficiency leading
    • to ischemia of ONH
    • VA down but better than AION
    • RAPD
    • CV decreased
    • VF: Altitudinal or Arcuate type
    • defects
  91. AION
  92. Hyperemic, or sectorialischemia
    • of disc
    • Crowded or small discs
    • Risk Factors
    • HBP (35-50%)
    • DM (10-25%)
    • Cardiovascular
    • Hypotensive events

    • VA loss in AM, from
    • nocturnalhypotension!!
    • ESR: Normal to Mild(Erythrocyte
    • Sedimentation Rate)
    • Approach:

    • ESR
    • C-Reactive Protein
    • Tx: Aspirin
  93. AAION
  94. 65 and older
    • infarction of disc 2ndaryto
    • GCA
    • scalp tenderness
    • fever
    • malaise
    • pain on jaw movement
    • weight loss

    • VA loss more severe w/ prodome
    • RAPD
    • CV decreased
    • Bilateral
    • ONH white chalky
    • Cup is large or normal
    • VF: Altitudinal Field Loss
    • Elevated ESR and C-Reactive
    • protein!!
    • Approach:

    • STAT referral forESR and
    • C-Reactive andtemporal biopsy

    Tx: IV steroids for 3 days
  95. Optic Neuritis
  96. Looks good but sees bad
    • Nerve inflammation
    • assoc.w/demyelinating diseasein young people
    • If Anterior ONH is swollen
    • Anterior ON

    • If Posterior ONH (retrolaminar)
    • Retrobulbar ON

    • Female
    • ON may be the initial sign of MS
    • Pain
    • VA decreased over a periodof
    • hours to days; then progressto 1-2 weeks
    • VA could be normal or Mild
    • Uhthoff Symptom
    • Temporary blurrying

    • RAPD
    • CV Loss >>> then VA Loss
    • + Brightness Sat. Test
    • VF: Central
    • Approach:

    • MRI - Plaques
    • CT will Not show

    • Tx: IV methylprednisone
    • followedby oral prednisone 15 days or interferon beta 1 IM
    • weekly.
  97. Atypical Optic Neuritis
  98. Before 15 and after 45
    • WORSENS beyond 14 days
    • Can be bilateral and
    • simultaneous
    • Causes:
    • Systemic and bacterial
    • diseases
    • Leber stellate(macular star)

    • Associated with Catscratch
    • disease
    • Recovery in 8 weeks for ONH
    • Approach
    • Work up for systemic
  99. Optic Neuritis in kids
  100. More anterior
    • Bilateral and simultaneous
    • Within 1-2 weeks of viral
    • infection or vaccination
    • Less assoc. with MS
    • Respond well to steroids
    • Good Px.
  101. Diabetic Papillopathy
  102. Disc edema
    • NO VA loss
    • NO RAPD
    • DM I (70%)
    • DM II (30%)
    • Unilateral (60%)
    • Bilateral (40%)
    • VF: generalized depressionof
    • enlargement of BS
    • Under 50
    • Hyperemic edema
    • Dilated telangiectatic vesselson
    • surface
    • Other eye has crowded disc
    • Resolves in 2-10 months.


    Consider Neuroimaging
  103. Papillophlebitis
  104. Young healthy adults 20-50 years
    • Males more than females
    • AKAs
    • Benign retinal vasculitis
    • Optic Disc vasculitis
    • Non-Ischemic CRVO
    • Big BS syndrome

    • Unilateral disc edema
    • Dilated tortuous veins hemes.

    • Variable reduction in VA
    • VF: Big BS
    • Self-resolving
    • Approach:
    • CBC, PT, PTT
    • ESR
    • Glucose
    • FA
    • CT scan/MRI
    • Syphilis/HIV


    • Steroids
    • Anticoagulants
    • F/U q 3 months
  105. Leber’s Hereditary Optic Neuropathy (LHON)
  106. Acute or subacute bilateralloss
    • of vision 2ndary to neuropathy
    • 2nd eye affected
    • within weeks or months

    • Mitochondrial gene mutations
    • men more than women
    • VA 20/200 or worse
    • RAPD if unilateral
    • Dyschromatopsia
    • VF: Central or Cecocentral
    • Signs:
    • Swollen and hyperemic,then
    • atrophic ONH
    • Circumpapullary telangiectatic
    • vessels
    • Opacification of AdjacentNFL
    • NO staining unlikepapillitis

    • Approach:
    • MRI if distinguishing cannot
    • be made from MS
    • EKG – heart conduction
    • Counseling
  107. ONH Glioma
  108. Juvenile
    • Benign Tumor
    • Assoc with neurofibromatosis
    • Proptosis is the MAIN
    • characteristic
    • Decreased VA
    • Optociliary Shunts
    • Another dilated vessel on
    • top of the ONH

    • Approach
    • MRI
    • Investigate Neurofib.

    • Tx: Sx resection
    • Chemo
  109. malignant Glioma of Adulthoon
  110. Rare
    • Middle age
    • Rapid progressive VA loss
    • Pain
    • Has
    • Unilateral, but if chiasmis
    • involved, Bilateral
    • Proptosis
    • Fundus: Venous Stasis Retinopathy
    • Spreads Intracranial and most
    • die in 1 YEAR!
  111. ON Sheath Meningiomas
  112. Benign tumors from the
    • intraorbital ON Sheath
    • Women > 40y/o
    • Unilateral
    • Slowly Progressive VA loss
    • RAPD
    • Dyschromatopsia
    • Proptosis later in disease
    • Diplopia
    • Gazed Evoked Amaurosis
    • 50/50 swelling and pallor
    • Optociliary Shunts
    • VF: Central defects
    • Approach:



    • Observation forVA >20/40
    • Radiation for VA getting
    • worse
    • NO SX!! Blindness!
  113. Nutritional and toxic neuropathies
    • Nutritional
    • Poor diet
    • Deficiency of B complex Vitamins
    • Folate and B 12 “detoxify
    • cyanide”
    • Pernicious anemia and Vit B
    • 12deficiency; gastric removal: strictvegetarians

    • Toxic and Toxic Agents
    • Smoking/alcohol
    • Methanol ingestion
    • Chloamphenicol
    • Ethylene glycol (antifreeze)
    • Etc.

    • Agents causing a NAAION like
    • Neuropathy
    • Sildenafanil
    • Amiodarone
    • Anti-arrhythmia drug
    • While like lesions on the cornea

    • Clinical Characteristics
    • BILATERAL progressive loss of
    • vision
    • Dyscromatopsia early in
    • thedisease (MAY BE INITIALSYMPTOM)
    • Bilateral
    • cecocentral/centralscotomas
    • NO RAPD - since bilateraland
    • Symmetrical
    • Optic Nerve Pallor(temporal
    • pallor) wedge typepallor
  114. Dominant Optic atrophy

    • Linked to chromosome 3q, 18q12
    • Decreased VA, bilaterally within
    • 1st decade
    • VA no worst than 20/200
    • Nystagmus if severely affected

    • ***LEBERS (20s – 30s) vs DOA
    • (1st decade)
    • ***ONH usually has R/G defects –
    • 2 exceptions
    • Glaucoma and DOA

    • Dyscromatopsia is a tritan
    • defect(B/Y defect)
    • VF: Bilateral
    • ceco-central/central scotomas
    • Temporal pallor
    • Retina: could see mild macular
    • RPE changes, no foveal reflex,peripapillary haloes, cup
    • excavation
    • Approach:
    • D-15
    • Hx
    • No genetic Testing commercially
    • Differentiate from bilateral
    • paleoptic neuropathies like nutritional/Toxic
    • VF:
    • R/O temporal
    • hemianopticdefects – consider MRI

    • Treatment
    • None

    • Differential Diagnosis:
    • Patients with slowly progressive
    • binocular VA loss, dyschromatopsia, binocular
    • central/cecocentralVF defects, pallor should be suspected of
    • having:

    • Toxic/Nutritional neuropathy
    • Hereditary Optic neuropathy

    • the two above have BILATERAL
    • appearances

    • Approach
    • protocol by Wills Eye, Burde
    • Order lab blood studies:
    • CBC
    • Chemistry panel
    • Vit B levels

    • If no Pallor: R/O Psychogenic, do
    • VEP
    • Order MRI/CT
    • If all above are negative: ERG to
    • R/Ocone-rod dystrophy
    • If ERG negative, R/O hereditary
    • ON:order blood test to R/O Leber’s
    • R/O poisoning: urine collection
    • forlead, thallium
    • Last thing done is lumbar
    • puncture:R/O occult inflammation or meningealneoplasm.

    • If all above negative, Tx with
    • thiamine 50mg/d, B12 and Multivitamins
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