Test 40
(Matching Paper: Neuro-ophthalmology)

In response to considerable discussion the Examinations Committee of the College has decided to update the format of the Part 3 MRCOphth Examination from April, 2003.

An extended matching paper will replace the existing MCQs and they will be no negative marking. The test will probably be easier than the previous format. To familiarize the candidates with the new formats, test 34 and onward will follow the new style as described below by the College.
 

40 questions over a 3-hour period. The questions will be divided as follows. 5 pathology questions 5 microbiology questions 15 general ophthalmology questions 15 Medicine and Neurology in relation to ophthalmology Extended matching questions are multiple choice items organized into sets that use one list of items in the set. The extended matching set includes four components  1. a theme  2. an option list  3. a lead in statement  4. at least four item stems, as illustrated below  This will involve 40 questions (probably 200 stems) over a period of 3 hours.

1. Match the physical signs (a-d ) with the most likely diagnoses (A-N) listed below:
 

A. Anton's syndrome B. Kennedy-Foster's syndrome C. Waadenburg's syndrome D. Wallenberg's syndrome E. Millard-Gubler's syndrome F. Gradenigo's syndrome G. Weber's syndrome

H. Raymond's syndrome I.  Benedikt's syndrome J. Parinaud's syndrome K. Nothnagel's syndrome L. Tolosa-Hunt's syndrome  M. Foville's syndrome N. Möebius's syndrome

 

a.	A 50 year-old hypertensive man developed a sudden onset slurring of speech,  vomiting and a right Horner's syndrome. He also had problem with standing up  straight. Ocular examination also revealed a horizontal jerky nystagmus. Answer D. The cardinal symptoms of the lateral medullary syndrome (Wallenberg 's syndrome) are sharp pain in the ipsilateral eye or burning of the face,  dizziness or vertigo, ataxia, hoarseness, clumsiness of the ipsilateral arm and leg, and difficulty standing or walking. The major ocular and oculomotor signs are an ipsilateral Horner syndrome, nystagmus, and occasionally  ocular pulsion toward the side of the lesion.
b.	A 60 year-old hypertensive man developed a sudden onset right complete right  third nerve palsy and a left hemiplegia.  Answer G. A third-nerve dysfunction plus contralateral hemiparesis implicates involvement of the ipsilateral cerebral peduncle. This is called Weber's syndrome.
c.	A 30 year-old man developed a right sixth nerve palsy and facial pain. CT scan revealed opacity of the mastoid air cells. Answer F. Gradenigo's syndrome. Where the sixth nerve enters the dura above the clivus and along the petrous ridge, it is susceptible to processes involving the adjacent mastoid air cells, such as mastoiditis. Inflammation in this region consists of abducens palsy, severe facial and eye pain (resulting from  involvement of the adjacent gasserian ganglion), and sometimes facial paralysis
d.	A 65 year-old diabetic woman developed a sudden-onset right facial palsy and a contralateral hemiplegia. Examination revealed a right abduction deficit. Answer E. Millard-Gubler syndrome combines an abduction deficit with contralateral hemiplegia and ipsilateral facial paralysis, implying involvement of the abducens fascicles, the pyramid, and the facial nerve fascicles.

2. Match the following findings (a-d) with the most likely cause or site of lesion (A-N) listed 
    below. 
 

A. orbital apex B. dilatation of the third ventricle C. dilatation of the fourth ventricle D. cavernous sinus E. red nucleus F. cerebral peduncle G.superior orbital fissure

H. inferior orbital fissure I.  cervicomedullary junction J.  ventral pons K. dorsal pons L.  occipital lobe M. pituitary gland N.  hypothalamus

 

a.	A 24 year-old girl developed morning headache and a bitemporal hemianopia.  CT scan revealed dilated lateral ventricles and a space-occupying lesion in the  brain stem. No lesions were seen in the pituitary or the hypothalamus region.  What may be responsible for the visual field defect? Answer B. The chiasm is located at the junction of the floor and the anterior wall of the third ventricle at the base of the brain. Obstructive hydrocephalus may  produce an enlarged third ventricle, which, acting as a mass, compresses the chiasm.
b.	A 75 year-old woman developed a sudden onset right third nerve. In addition, she also developed a left involuntary tremor. Answer E. A oculomotor palsy and contralateral tremor suggest a lesion in the region of  the red nucleus commonly called Benedikt's syndrome
c.	A 80 year-old man developed a right facial palsy and a right horizontal gaze palsy. In addition, he had a right Horner's syndrome and loss of sensation to the right face. Answer J. Lesion of the ventral pons also called Foville's syndrome. Foville's syndrome combines an abduction or horizontal gaze deficit with ipsilateral facial weakness, ipsilateral loss of taste, ipsilateral facial analgesia, ipsilateral Horner's syndrome, and ipsilateral deafness. The structures affected are the abducens fascicles or nucleus, the facial nerve fascicles,  the nucleus of the tractus solitarius, the spinal tract of the trigeminal nerve, the central tegmental tract, and the cochlear nuclei, respectively .
d.	A 32 year-old woman developed a painful right eye and proptosis. Examination  revealed normal vision but the movement of the right eye is restricted and the  right forehead had decreased sensation to touch and pain. The left eye examination  was normal. Answer G. The history and physical signs suggest a lesion in the superior orbital fissure. The sensory nerves to the forehead travel through the superior orbital fissure.  The presence of a mass lesion in the orbital apex would produce a compressive optic neuropathy in addition to dysfunction of the ocular motor nerves, and  proptosis. Lesion of the cavernous sinus produces minimal or no proptosis (except in carotid cavernous fistula) and the contralateral eye tends to be affected.

 

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