1. The following are true about isolated fourth (trochlear nerve)
    palsy:

    a. head trauma is the most common cause in children

    b. aneurysm is a common cause in adult

    c. the head is usually tilted away from the palsied side

    d. congenital form tends to have a large vertical fusional range

    e. vertical prism is useful in correcting the torsional diplopia

answer1.    a.F    b.F    c.T    d.T    e.F
In trochlear nerve palsy:
congenital cause is commoner in children than trauma
trauma is a common cause in adult
prism corrects vertical but not torsional diplopia.
 

2. The following signs are useful in distinguishing between the
    congenital and acquired form of Horner's syndrome:

    a. absent light reflex of the affected eye

    b. lighter iris colour of the affected eye

    c. decreased facial sweating of the affected side

    d. dilatation of the affected pupil with 10% cocaine

    e. dilatation of the affected pupil in response to 1% adrenaline
 

answer2.    a.F    b.T    c.F    d.F    e.F
Heterochromia is useful in distinguishing between congenital and acquired Horner's syndrome.
Pupil in Horner's syndrome responds to right but may be difficult to observe due to miosis.
Decreased sweating is seen in congenital and acquired form
Both acquired and congenital Horner's syndrome show decreased pupil dilatation to 10% cocaine.
 

3. Palinopsia occurs in:

    a. use of hallucinogens

    b. parietal lobe lesion

    c. occipital lobe lesion

    d. frontal lobe lesion

    e. migraine
 

answer3.    a.T    b.T    c.T    d.F    e.T
Palinopsia is the persistence of visual image which last longer than normal.
 

4. In spasmus nutans:

    a. the age of onset is usually between 4 and 18 months of age

    b. the nystagmus is classically horizontal

    c. the condition does not requires further investigation

    d. the eye movement is symmetrical

    e. spontaneous resolution commonly occurs
 

answer4.    a.T    b.F    c.F    d.F    e.T
In spasmus nutans, ocular oscillation, head nodding and torticollis are classically seen. The nystagmus is usually in all direction and asymmetrical.
Neurology work-up is important as the condition may be mimicked by neurological tumour such as neuroblastoma.
The onset is usually between 4 and 18 months of age and spontaneous resolution occurs commonly.
 

5. Downbeat nystagmus occurs in:

    a. lithium toxicity

    b. alcohol intake

    c. Arnold-Chiari's syndrome

    d. middle ear diseases

    e. spinocerebellar degeneration
 

answer5.    a.T    b.T    c.T    d.F    e.T

Downbeat nystagmus may occur due to lesions

in the cervicomedullary pathway such as Arnold-Chiari's syndrome or spinacerebellar degeneration.
Other causes include: intoxication with alcohol, anticonvulsants and lithium.
 

6. Bitemporal hemianopia may be seen in:

    a. tilted disc

    b. bilateral ischaemic optic neuropathy

    c. dermatochalasia

    d. sectorial retinitis pigmentosa

    e. retinoschisis
 

answer6.    a.T    b.F    c.T    d.T    e.T
Ischaemic optic neuropathy causes altitudinal field defect.
 

7. Vertical gaze is impaired in the following conditions:

    a. internuclear ophthalmoplegia

    b. walled-eye syndrome

    c. juvenile Gaucher disease

    d. progressive supranuclear palsy

    e. Sylvian aqueduct syndrome
 

answer7.    a.F    b.F    c.T    d.T    e.T
Internuclear ophthalmoplegia and walled-eye syndrome involve the horizontal gaze centre.
 

8. The following findings make benign intracranial hypertension
     unlikely:

    a. bilateral sixth nerve palsy

    b. morning headache and nausea

    c. increased protein in the cerebrospinal fluid

    d. enlarged ventricle on brain scan

    e. hard exudate in the macula
 

answer8.    a.F    b.F    c.T    d.T    e.F
The cerebrospinal fluid and brain scan are normal in benign intracranial hypertension.
 

9. Optic nerve hypoplasia is associated with:

    a. maternal diabetes mellitus

    b. maternal alcoholism

    c. hypopituitarism

    d. maternal use of phenytoin

    e. maternal folate deficiency
 

answer9.    a.T    b.T    c.T    d.T    e.F
 

10. In a patient with bilateral centrocecal scotoma, the following
      tests are useful in diagnosis:

    a. full blood count

    b. serum folate level

    c. liver function tests

    d. serum copper level

    e. ESR
 

answer10.    a.T    b.F    c.T    d.F    e.F
Bilateral centrocecal scotoma is typically seen in nutritional optic neuropathy. It is seen in vitamin B12 deficiency and patients who abuse alcohol.
Full blood count will shows megaloblastic anaemia typical of vitamin B12 deficiency. Liver function tests will be abnormal in alcoholic.
 

11. In non-arteritic ischaemic optic neuropathy:

    a. optic disc oedema is common

    b. embolism is the cause in the majority of cases

    c. visual loss is usually more severe than arteritic ischaemic optic
        neuropathy

    d. a small cup-to-disc ratio is a risk factor

    e. optic nerve fenestration is useful in improving final visual outcome
 

answer11.    a.T    b.F    c.F    d.T    e.F
Embolism is not thought to be a common cause of non-arteritic ischaemic optic neuropathy. Therefore, carotid artery imaging and echocardiogram are not recommended.
There is no evidence that optic nerve fenestration is useful.
 

12. In contrast to surgical third nerve palsy, medical third nerve
      palsy:

    a. does not affect pupillary response to light

    b. does not affect accommodation

    c. does not cause upper lid elevation on attempted downgaze

    d. does not cause complete ptosis

    e. causes a decreased in intraocular pressure
 

answer12.    a.T    b.T    c.T    d.F    e.F
In medical third nerve palsy, the parasympathetic pathway is relatively unaffected and therefore light reflex and accommodation are intact.
Upper lid elevation on attempted downgaze is caused by aberrant third nerve regeneration and is seen in compressive (surgical) third nerve palsy.
Paralysis of the recti decrease the intraocular pressure due to reduce muscle tone on the globe.
 

13. In optic neuritis:

    a. there is usually progression over the first three weeks from onset

    b. pain on ocular movement is usually worse on adduction

    c. the central scotoma may worsen with raised in body temperature

    d. systemic steroid has been shown to affect the final visual outcome

    e. a swollen disc make the diagnosis unlikely
 

answer13.    a.F    b.T    c.T    d.F    e.F
Progression over more than two weeks should raise the possibility of a compressive lesion. Systemic steroid may speed up recovery but does not affect the final visual outcome.
The disc may be normal or swollen in optic neuritis.
 

14. In myasthenia gravis:

    a. the horizontal recti are more commonly affected than the vertical
        recti

    b. there is a delayed tendon reflex

    c. the pupillary response to light is not affected

    d. steroid may worsen the muscular problems

    e. neonates born to mother with the disease may be affected due to
        the anticholinesterase receptor antibodies closing the placenta
 

answer14.    a.F    b.F    c.T    d.T    e.T
Vertical diplopia is more common than horizontal diplopia in myasthenia gravis. Involvement of the tendon reflexes raises the possibility of Lambert-Eaton's syndrome.
Steroid may initially worsen the muscular problems especially respiratory function.
 

15. The following are true:

    a. opticokinetic drum can be used to differentiate a lesion in the parietal
        lobe from that of a occipital lobe.

    b. cerebral dyschromatopsia is associated with bilateral superior
        homonymous hemianopia.

    c. postfixation visual loss in bitemporal hemianopia

    d. afferent pupillary defect and homonymous hemianopia in lesion of
        the optic tract

    e. sensory inattention is associated with left inferior homonymous
        quadrinopia in a right handed person
 

answer15.    a.T    b.T    c.T    d.T    e.T
Cerebral dyschromatopsia occurs in bilateral temporal lobe lesion and therefore bilateral superior homonymous hemianopia.
A lesion of the right parietal lobe in a right handed person results in sensory inattention.
 

16. In Parinaud's syndrome:

    a. the lesion is in the dorsal mid-brain

    b. light-near dissociation is a feature

    c. accommodative spasm occurs on attempted upgaze

    d. convergence-retraction nystagmus occurs with vertical saccades

    e. demyelination is a known cause
 

answer16.    a.T    b.T    c.T    d.T    e.T
Parinaud's syndrome is also known as dorsal mid-brain syndrome.
 

17. The following are true:

    a. Uhtoff's symptom refers to a decrease in vision with an increase in
        body temperature

    b. prosopagnosia occurs with a bilateral medial occipitotemporal lesion

    c. in Riddoch phenomenon, the patient can perceive objects in motion
        but not stationary objects.

    d. skew deviation occurs in lesion of the supraneuclear vertical gaze
        pathway

    e. Anton's syndrome is associated with denial of blindness
 

answer17.    a.T    b.T    c.T    T    d.T    e.T
Riddoch phenomenon occurs with cortical blindness and the patient can see moving objects but not stationary ones.
Prosopagnosia is inability to distinguish faces.
In Anton's syndrome, the patient usually has bilateral cortical blindness but uses confabulation to deny blindness.
 

18. In Benedikt's syndrome:

    a. third nerve palsy is present

    b. there is a contralateral weakness

    c. there is a contralateral tremor

    d. there is contralateral sensory loss

    e. the facial nerve is involved.
 

answer18.    a.T    b.F    c.T    d.T    e.F
 

19. In Leber's optic neuropathy:

    a. DNA analysis is useful

    b. the offsprings of an affected man have a 50% chance of
        acquiring the disease

    c. in the acute phase a macular star is typically seen

    d. the optic disc is hyperaemic with telangiectatic capillaries

    e. fluorescein angiography in the acute phase shows leakage in
        the optic disc
 

answer19.    a.T    b.F    c.F    d.T    e.F
The condition is transmitted via the maternal mitochondrial DNA and therefore the offsprings of an affected man will not be affected.
Despite the telangiectatic capillaries, fluorescein angiography does not shows any leakage.
 

20. In thyroid eye disease:

    a. the medial and inferior recti are the most commonly affected
        extraocular muscles.

    b. smoker is more likely to be affected than non-smoker

    c. optic nerve fenestration is useful in patients with optic nerve
        compression

    d. upgaze is most commonly affected in patients with ocular
        motility problems

    e. the thyroid function test always shows hyperthyroidism
 

answer20.    a.T    b.T    c.F    d.T    e.F
Decompression is the treatment of choice in patient with optic nerve compression.
The thyroid function may be normal in thyroid eye disease.
 

21. In Argyll-Robertson's pupils:

    a. the condition occurs in acquired but not congenital syphilis

    b. the pupils dilate poorly with atropine

    c. the irregularity of the pupils are caused by iritis

    d. the pupils dilate with topical cocaine

    e. the lesion is in the rostral area of the Edinger-Westphal nucleus.
 

answer21.    a.F    b.T    c.T    d.F    e.T
It is reported in both congenital and acquired syphilis.
 

22. In Adie's (tonic) pupil:

    a. the pupil may not respond to light or accommodation in the acute
        stage

    b. Guillain-Barré syndrome is a known cause

    c. the pupil constricts with 2.5% mecholyl solution

    d. there is usually a permanent loss of accommodation

    e. the condition may be confused with Argyll-Robertson's pupil.
 

answer22.    a.T    b.T    c.T    d.F    e.T
The cycloplegia usually returns with time.
In long-standing cases, the pupil becomes miosed and may be confused with Argyll-Robertson's pupil.
 

23. In a dilated pupil:

    a. a light-near dissociation is seen with third nerve palsy

    b. failure of constriction to 1% pilocarpine is seen in third nerve palsy

    c. failure of constriction to 1% pilocarpine occurs with mydriasis
        induced by atropine

    d. problem with accommodation is a useful sign in distinguishing
        mydriasis induced by atropine from that caused by third nerve
        palsy

    e. consensual light reflex of the normal eye is absent in third nerve
        palsy
 

answer23.     a.F    b.F    c.T    d.F    e.F
Third nerve palsy constricts with 1% pilocarpine.
 

24. The following are true:

    a. Cogan's rule: a patient with homonymous hemianopia but otherwise
        neurologically intact is caused by a lesion in the occipital lobe

    b. Wernicke's hemianopic pupillary response: occurs in optic tract field
        defect

    c. Gertman's syndrome: lesion in the non-dominant parietal lobe

    d. Marcus Gunn's pupil: diagnostic of optic neuritis

    e. Foster-Kennedy's syndrome: lesion in the optic tract
 

answer24.    a.T    b.T    c.F    d.F    e.F
In Wernicke's hemianopic pupillary response a light shone at the blind half-field of an optic tract lesion will not give a pupillary response because the pupillary fibres are affected to the same degree as the visual fibres. Clinically, it is not a useful sign as it is not possible to shine light at only half the retina.
Marcus Gunn pupils can be seen in optic neuropathy of any causes.
In Foster-Kennedy's syndrome, the lesion is usually at the intracerebral optic nerve leading to optic atrophy in one eye and papilloedema in the other.
 

25. The following are true about visual field defects:

    a. macular sparing is commoner with an anterior rather than a
        posterior lesion of the calcarine cortex

    b. horizontal sectoranopia is a feature of lateral geniculate body
        lesion

    c. an unilateral field loss rules out a lesion in the post-chiasmal region

    d. a homonymous hemianopia with temporal sparing is seen in lesion
        of the posterior calcarine cortex

    e. altitudinal defect is a feature of glaucoma
 

answer25.    a.T    b.T    c.F    d.T    e.F
A unilateral temporal crescent defect may occur with lesion in the anterior calcarine cortex.
Altitudinal field defect is a feature of ischaemic optic neuropathy.
 

26. In a left optic tract lesion:

    a. a right afferent pupillary defect may be present

    b. the visual field shows congruous homonymous hemianopia

    c. the left optic disc may show temporal pallor

    d. the right optic disc may show nasal pallor

    e. the lesion may result from a pituitary adenoma
 

answer26.    a.T    b.F    c.T    d.T    e.T
A right relative afferent pupillary defect results from a greater representation of the afferent pupillary fibres of the right eye than of the left eye in the left optic tract.
The visual field is usually incongruous.
The localized disc pallor is related to the fibres found in the tract. The left temporal pallor is due to the presence of uncrossed fibres from the temporal retina. The right nasal pallor is due to the presence of crossed contralateral nasal retina nerve fibres in the left optic tract.
A post-fixed pituitary adenoma can produce an optic tract lesion.
 

27. Optic nerve gliomas:

    a. usually occur in the third decade of life

    b. proptosis is the most common presentation

    c. are usually bilateral

    d. cause death through cerebral invasion

    e. require early surgical excision
 

answer27.    a.F    b.F    c.F    d.F    e.F
The majority occurs in children and visual loss is the most common presentation.
Cerebral invasion is rare and the treatment is usually conservative.
 

28. Tuberous sclerosis has the following features:

    a. mental retardation

    b. ashleaf lesion best seen with Wood's light

    c. mulberry tumours which contain calcification

    d. presence of café au lait patches

    e. over 90% of the cases have a positive family history
 

answer28.    a.T    b.T    c.T    d.T    e.F
Mental retardation and epilepsy are common although some sufferers may be mentally normal.
About 50% of cases are sporadic.
 

29. In visual evoked potential (VEP):

    a. the latency is prolonged in recovered optic neuritis

    b. the amplitude is normal in recovered optic neuritis

    c. it is essentially a test of the macula

    d. the result is abnormal in patients with ocular albinism

    e. it can be used to detect malingering
 

answer29.    a.T    b.T    c.T    d.T    e.T
Due to complete decussation of the optic nerve fibres, patients with ocular or oculocutaneous albinism have abnormal VEP.
 

30. In  type 1 neurofibromatosis, the following signs may be seen:

    a. pulsatile proptosis

    b. bilateral acoustic neuroma

    c. Lisch's nodules

    d. cerebral meningioma

    e. cavernous haemangioma of the retina
 

answer30.    a.T    b.F    c.T    d.T    e.F
Pulsatile proptosis is caused by aplasia of the sphenoid bone.
Bilateral acoustic neuroma is a feature of type 2 neurofibromatosis
 
 

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