sponsored by
Adrian Parnaby-Price MA, MB, BChir (Cantab), FRCSEd
The College of
Neurology and the eye
Optometrists has
awarded this
article 2 CET
Case histories
The College of
Optometrists
credits. There are
Module 2 part 12 is devoted to five case histories to demonstrate the real-life
12 MCQs with a
clinical presentations of neuro-ophthlamic conditions and some of the
pass mark of 60%.
important features to aid diagnosis and management.
CASE 1 CASE 2
related to the ocular problem but may be
A 45-year-old female barrister presented to
A 36-year-old female director of sales and
related to systemic disease.
her optometrist with a two week history of
marketing presented to her General
intermittent diplopia and mild blurring of
Practitioner with a history of  droopy
vision in the left eye. A friend had 2. Why has this been noticed by
eyelids in the evenings which she first
commented on her small right pupil at a a friend but not by the patient?
noticed in photographs taken some 12
barbecue party six weeks earlier, but she The friend has noticed the anisocoria but
months earlier. This had been getting worse
had not noticed this herself. On specific has mistaken the normal, smaller right
for around the last 3-4 months.
questioning, she admitted to headaches pupil as pathological instead of the larger,
She had worn soft contact lenses for
which were either bitemporal or abnormal left pupil. In the bright daylight
12 years without significant problems and
occasionally felt as a sharp stab over the at the barbecue, parasympathetic pupil
switched to daily disposable lenses
left temple. She only had a three year old constriction failure is more noticeable as
18 months earlier. The GP requested an
pair of reading glasses with +1.50DS the affected pupil fails to constrict. In the
optometrist check-up to exclude lens
correction right and left. dimmer indoor light of the patient s home
problems as the cause and she presented
On examination, vision was 6/6+1 right where she looks at herself in a mirror,
for review early next morning before flying
with a +1.25DS correction, and 6/5 left neither pupil is particularly constricted and
to a series of business meetings in the US
with a +1.50/-0.50 x 85 correction. She therefore parasympathetic anisocoria is
later the same day.
had no manifest squint in the primary more difficult to see.
On direct questioning she reported that
position. Cover testing revealed a slight
the lids might be droopy either as one or
exophoria in primary position which 3. What is the squint?
both together and she was having
became manifest on right gaze. There was The patient is most likely to be exhibiting
occasional blurring of vision and diplopia.
anisocoria with the right pupil slightly the effects of a left partial third nerve
This could be remedied by putting cold
smaller than the left. There was no RAPD, palsy for the reasons outlined earlier.
compresses over the eyes for 5 minutes.
but the left pupil was sluggish and did not
She tended to wear her lenses from early
constrict well. The media were clear and 4. What is the significance
morning until late at night although her
the discs were normal. There were two dot of the retinal haemorrhages?
optometrist had suggested at review six
haemorrhages in the right mid-peripheral The most common causes of retinal
months earlier that she should be cutting
retina but none in the left. haemorrhages seen as an isolated finding
down on the total wearing time due to
are diabetes mellitus or vascular
 minor overwear problems . She was
Questions hypertension. Both of these may be
otherwise well although has lost some
1. Which is the abnormal eye? associated with nerve lesions, in
weight recently.
2. Why has this been noticed by particular third nerve palsies and pupil
Vision was 6/5+ in both eyes with
a friend but not by the patient? abnormalities.
lenses. The lenses were equivalent to
3. What is the squint?
spectacle correction of  5.50/-1.00 x 60
4. What is the significance of the retinal 5. What should the
right and  4.50/-1.50 x 100 left. There
haemorrhages? optometrist do next?
were numerous follicles and moderate
5. What should the optometrist do next? The symptoms and signs are those of a
injection of the palpebral conjunctiva in
painful third nerve palsy involving the
both eyes (Figure 1). Both corneae had
Answers pupil. The most important diagnoses
1. Which is the abnormal eye? include a structural/compressive lesion
The left eye is abnormal. Although vision is such as an intracranial tumour or aneurysm
Figure 1 Conjunctival follicles
subjectively reduced in the left eye, in fact which constitute a medical emergency and
the astigmatism more than accounts for indicate immediate referral to hospital
this and vision is approximately normal and services for an urgent CT or MRI scan.
At hospital this patient was found to be
equal in both eyes with appropriate
refractive correction. There is no afferent hypertensive and had a blood pressure of
defect as this condition is of efferent 230/130. She had an aneurysm of the
pathways. However, the left pupil is carotid artery in the left cavernous sinus
abnormal and fails to respond properly to which was treated neurosurgically the
formal pupil testing and there is an morning following presentation to the
exotropia on right gaze suggesting a left optometrist. She made an almost complete
third nerve palsy rather than an esotropia recovery of pupil and nerve palsy and did
suggestive of a right sixth nerve palsy. The not suffer the potential progression of the
retinal haemorrhages are not directly aneurysm to cerebro-vascular accident.
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CASE 2 continued
This time ocular motility appeared to
Patients with myaesthenia gravis have an
have returned to normal although
increased risk of other autoimmune
prolonged upgaze induced a slight return
diseases and thyroid dysfunction is
of the 1-2mm ptosis of the right eyelid
present in 5-8% of myaesthenic patients.
which again recovered with the
Other features of thyroid eye disease
application of a cold compress.
include prominent globes and orbital
The patient was referred to a hospital
congestion with injection of conjunctival
specialist for assessment. and scleral vessels and mild lid swelling
with ptosis. Extraocular muscle
Questions involvement can mimic mild or early
1. What is the diagnosis and what nerve palsies.
is the cause of the condition?
2. Why has the patient deteriorated
5. What is internuclear
3. Why do the cold compresses
Figure 2 The result of overwear ophthalmolplegia?
improve symptoms
Internuclear ophthalmoplegia is caused by
mild vessel infiltration of the cornea and 4. What associated condition
a lesion in the medial longitudinal
mild scleral injection consistent with might exhibit ocular signs?
fasciculus (a neural tract running through
overwear (Figure 2). The eyes appeared 5. What is internuclear
the brainstem carrying impulses from the
slightly prominent with very mild ophthalmolplegia?
vestibular nuclei to the cranial nuclei). It
thickening of the lids. The upper lid 6. What is the management
is characterised by limitation of adduction
margins appeared at normal position and of the primary condition?
in one eye with ataxic nystagmus in the
equal on both eyes, cutting the cornea abducting eye and may be bilateral. The
just below the upper limbus. There were Answers pupils are not involved in the lesion.
no afferent or efferent pupil defects. 1. What is the diagnosis and what Causes of lesions in this area include
The optometrist diagnosed a mild is the cause of the condition? multiple sclerosis, tumours and vascular
overwear problem and gave appropriate Myaesthenia gravis, caused by impaired events.
advice suggesting a review in one month s neuromuscular transmission from the
time. production of auto-antibodies to
6. What is the management of the
Late in the afternoon 4 days later, she acetylcholine receptors in the motor
primary condition?
returned to the optometrist with endplates of striated muscles.
Ocular involvement is present in 90% of
significant increase in symptoms of myaesthenic patients and is the
diplopia and lid problems since returning 2. Why has the patient deteriorated?
presenting complaint in 75% with most
to the UK the day before. She insisted Although it is usually physical activity
progressing to systemic symptoms within
that she had reduced her lens wearing which causes increase in severity of the
two years. Diagnosis is made by
time to only a few hours each day during condition, tiredness (including that from
identifying acetylcholine receptor
meetings. jet-lag) can worsen symptoms
antibodies in the blood although only
Vision was 6/5+ in both eyes with no significantly. Symptoms are characterised 30% of myaesthenic patients have these.
pupil abnormalities. There was by their extremely rapid variability, often If indicated, intravenous edrophonium
improvement in the palpebral conjunctival within minutes and are described by chloride (Tensilon) relieves symptoms and
injection, although there were still some patients as  failure to move rather than signs immediately (particularly of ptosis)
follicles and the corneal vessels were less  tiredness and aching such as a fatigue and is diagnostic. Electromyelography can
prominent but the scleral vessels following exercise. be helpful but is rarely used in clinical
appeared to be more full than normal, practice.
more so on the right. The upper lids 3. Why do the cold compresses improve Ocular myaesthenia alone may be
appeared to be slightly fuller and bisected symptoms? managed by ocular occlusion, prism
the cornea 1.5-2mm below the upper Any lid swelling due to contact lens spectacles, oral pyridostigmine and
limbus in the right eye. Ocular motility problems will be aided by cold but in this systemic steroids. Surgical thymectomy
testing revealed diplopia in all extremes case it is more likely that simply the may be indicated and plasmaphoresis
of gaze, particularly on upgaze. There was resting of the extra-ocular muscles during has been used. It is important to
the suggestion of a right third nerve eye closure allowed recovery. The extreme monitor thyroid status after
weakness with abnormal abduction of the variability of phorias or tropias during the diagnosis.
left eye, but this was not consistent with same examination is very suggestive of In this patient treatment with oral
an internuclear ophthalmoplegia and was myaesthenia. Myaesthenia gives rise to pyridostigmine and reduction in contact
not clearly apparent on cover testing. The generalised muscle weakness, which can lens wear time did not significantly
optometrist noted ptosis towards the end mimic any of the patterns of the ocular improve the scleral and episcleral
of testing, more noticeable in the right nerve palsies or central lesions including injection although the corneal vessels
eye. The patient complained of discomfort gaze palsies, INO and nystagmus but the regressed somewhat. Symptoms of
and was offered a paper napkin with cold pupils are not affected. diplopia were completely alleviated
water to use as a compress which and the ptosis has resolved. She
appeared to reduce the ptosis and allow 4. What associated condition might remains well two years after initial
re-examination after a few minutes. exhibit ocular signs? presentation.
34 December 1, 2000 OT
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Module 2 Part 12
in patients with multiple sclerosis. Because
CASE 3 uveitis can be treated and can result in
severe ocular pathology, it is very important
A 23-year-old fifth year medical student 4. Are the two conditions associated? to actively exclude uveitis in any patient
presented to his ophthalmology lecturer 5. What investigations might be with multiple sclerosis who complains of
during a clinical attachment. He complained helpful in establishing a diagnosis visual loss, even in those with previous optic
of a left retrobulbar ache over the previous for the right eye? neuritis and during relapses at other sites.
four days and some blurring of vision in the 6. What are the management options for
left eye over the last 24-48 hours. He was the right eye and was the previous 5. What investigations might be helpful
otherwise fit and well. ophthalmologist justified in not in establishing a diagnosis for the right
Vision was 6/12 right, 6/9 left unaided venturing likely underlying diagnostic eye?
with no improvement in acuity with pinhole. possibilities? During acute CNS inflammation, lumbar
Subjective red appreciation was reduced in puncture to obtain CSF samples can show
the right eye but normal in the left. Ishihara Answers antibodies and cells characteristic of disease.
colour vision was 10/16 + test plate right, 1. What is the diagnosis in the left eye? In old disease or in remission this is unlikely
16/16 + test plate left. Ocular movements Anterior uveitis (iritis) to yield a positive result. MRI scanning will
were full with no diplopia or obvious show current or old areas of demyelination
restriction of movement although there was 2. What is the treatment for this and is the most reliable diagnostic tool.
a slight increase in the retrobulbar ache in condition? What are the management options for the
the left eye on extreme version. The right Topical steroids to suppress inflammation right eye and was the previous
eye was white with no anterior segment and mydriatics to relieve pain and prevent ophthalmologist justified in not venturing
pathology, but there was moderate injection posterior synaechiae. Posterior synaechiae likely underlying diagnostic possibilities?
of the scleral and conjunctival vessels of the results in a  fixed pupil caused by leakage of Up to approximately 60% of patients with
left eye with cells and flare in the anterior protein-rich serum and cells into the optic neuritis will go on to develop other
chamber. There was a right RAPD. After aqueous blocking the area between the pupil clinical signs of multiple sclerosis in later
dilation, the right optic disc was pale margin and the anterior lens. life. However, the diagnosis of multiple
(Figure 3) although the left disc was sclerosis is made only when two or more CNS
normal. 3. What is the likely pathology in the lesions can be demonstrated, separated by
After more careful questioning, the right eye? time and anatomical site. In this patient, a
patient gave a history of a temporary loss of Optic atrophy. In view of the suspicion of single episode of optic neuritis does not
vision in the right eye some 4 years earlier other neurological abnormalities in this age meet the diagnostic requirements and even
which had apparently recovered without group the most likely underlying diagnosis is speculation must be restricted. Even when
treatment. The ophthalmologist who had multiple sclerosis suggesting that the optic clearly diagnosed, use of specific
seen him during that episode at the atrophy is secondary to old optic neuritis. prophylactic and acute anti-inflammatory
student s home town had not offered a Optic neuritis can affect any part of the treatments in multiple sclerosis is extremely
specific diagnosis but seemed confident that optic nerve but will only produce clinical limited. During acute relapse, high dose
there would be no sequelae. He also reported changes if the portion immediately adjacent intravenous steroids will shorten the
an episode of mild weakness of his left hand to the globe is involved. This is only the duration of the attack but have no influence
and lower arm about six months earlier case in a minority of cases. In an acute on the severity of residual disability later on.
which had again resolved after 2-3 weeks for attack, macular exudates are relatively Interferon may influence the incidence of
which he did not seek medical advice. On frequent if the disc is involved as protein relapse in certain subtypes of multiple
physical examination the tendon reflexes of and lipid-rich fluid leaks through diseased sclerosis in specific patients but there is
the arms were asymmetrical with increased vessel walls, forming linear streaks (macular currently no clinical test to identify whether
responses on the left (upper motor neurone star) as deposits track along the nerve fibre a patient would benefit and the potential
pattern). layer. In addition, the cerebrospinal fluid costs and side-effects currently limit its use.
(CSF) may contain inflammatory cells. In this patient it would not be reasonable to
Questions Other important differential diagnoses in commence prophylactic interferon treatment
1. What is the diagnosis in the left eye? this patient include other inflammatory on the basis of a single episode of optic
2. What is the treatment conditions such as Behcet s disease, neuritis.
for this condition? congenital and hereditary optic atrophy (but In the absence of a firm diagnosis and in
3. What is the likely pathology not likely in view of the recovery of this eye the absence of a reliable prophylactic
in the right eye? and the normal fellow eye), choroiditis and treatment, the first ophthalmologist was
retinitis pigmentosa (again, unlikely in view probably fully justified in not discussing the
of the absence of other findings). Optic potential underlying condition.
nerve compression of the right eye and toxic Six months later this patient suffered an
or infective conditions also seem unlikely. acute episode of paralysis of the right leg at
which time an MRI scan revealed multiple
4. Are the two conditions associated? areas of demyelination throughout the CNS.
Yes. Demyelinating disease (multiple He was not treated for the acute attack but
sclerosis) is the result of aberrant leucocyte was subsequently commenced on interferon.
activity in the CNS, which is embryologically He has had specific career counselling and is
and immunologically similar to the eye. continuing with his career in medicine but
Uveitis and multiple sclerosis are therefore has decided to enter radiology as a speciality
likely to represent differing targets of a as it was considered to be the area in which
similar malfunction in the immune system any physical disability is least likely to affect
Figure 3 Optic atrophy his career.
and there is a strong association of uveitis
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Answers
CASE 4
1. Where is the lesion?
Right sixth nerve nucleus. After exiting the
A 52 year old company director presented to of recent improvement and previous
nucleus, there is no anatomical site which
his optometrist with a two week history of hypertension. A diagnosis of ischaemic sixth
would permit involvement of the
 blurring of vision on looking to the right. nerve palsy secondary to hypertension was
contralateral third nerve. The ipsilateral
The optometrist noted that this was not made. His notes also recorded normal
seventh nerve passes backwards from its
causing significant symptoms but suspected movement in the left eye, no pupil
nucleus and passes around and behind the
that the patient was adopting a head turn abnormalities and normal optic discs with a
sixth nucleus allowing early involvement of
to the right to compensate. The optometrist 0.3 cup to disc ratio. The patient was given
the seventh nerve (see Figure 4).
advised the patient to visit his GP as soon an appointment in the orthoptic clinic for a
as possible and gave a referral letter to the Hess chart to quantify the defect and a
2. Why is the left medial rectus involved?
patient to take with him which is return visit to the general clinic was made
40% of the sixth nerve cell bodies project to
summarised as follows: for 1 month s time.
the contralateral medial rectus to cause
Vision right 6/12 unaided improving to The Hess chart revealed a fairly marked
adduction of the fellow eye and facilitate
6/6 with +0.50/+0.50 x 75. Vision left 6/9 right abduction deficit and a mild left
consensual gaze movement. Loss of this
unaided improving to 6/6 with 0.00/+0.50 x adduction weakness.
projection therefore contributes to a gaze
100. There is a right sixth nerve weakness At the general clinic one month later, the
palsy.
giving horizontal diplopia of two weeks patient complained of worsening diplopia
duration. History of hypertension  on and an alteration in the appearance of the
3. What is the likely underlying
treatment. Suggest urgent referral to right side of the face. The diplopia was
diagnosis?
ophthalmologist for assessment. particularly marked on right gaze and he
Ischaemia or tumour (glioma or leukaemia
The patient visited his GP two days later. was no longer able to overcome this by
deposits). In a younger age group multiple
The GP countersigned the referral, asked the head turn to the right. The ophthalmologist
sclerosis is also an important cause and in
patient to make an appointment at the local on this occasion found almost complete
children 50% of sixth nerve palsies overall
hospital Early Referral Clinic and checked right sixth nerve palsy and a marked left
are attributable to neoplasm if trauma is
the blood pressure which he found to be adduction weakness. There was a mild right
excluded.
slightly high at 170/100. He increased the facial nerve weakness but no other cranial
strength of the patient s medication and nerve signs. The site of the lesion was
4. Why is the clinical condition changing?
made an appointment to re-check the blood re-diagnosed and MRI scans and neuro-
The apparent progression of the condition
pressure in 3 weeks. On contacting the vascular studies performed.
strongly suggests a progressive aetiology.
hospital, the patient was given an
The history is consistent with an early pure
appointment for 10 days which he missed as Questions
right sixth nerve palsy at the presentation to
he was away on business. He was first seen 1. Where is the lesion?
the optometrist with an early left medial
at the hospital almost a month after the 2. Why is the left medial
rectus weakness by the time he was first
optometrist s consultation. rectus involved?
seen in the early referral clinic which would
The duty SHO examined the patient. The 3. What is the likely
reduce diplopia on right gaze. As the muscle
diplopia had subjectively improved over the underlying diagnosis?
weakness became worse, the further
previous 2-3 weeks and was not causing 4. Why is the clinical
reduction in right gaze and dyskinesis caused
significant problems. The SHO confirmed a condition changing?
increased symptoms. As the nuclear lesion
right sixth nerve palsy which appeared fairly 5. What should be the advice to this
enlarged, the seventh nerve has become
marked, but was influenced by the history patient about driving?
involved.
5. What should be the advice to this
patient about driving?
The DVLC requirements for driving stipulate
that someone with diplopia may not drive a
car in the UK. Failure to contact the DVLC
with such a condition would invalidate any
insurance policies rendering the patient
liable to legal proceedings regarding fitness
to drive and driving without insurance.
In spite of an accurate anatomical
diagnosis, MRI and neurovascular imaging
failed to identify a specific lesion. A
presumptive diagnosis was made of
brainstem microvascular occlusion (limited
cerebrovascular accident (CVA)). The patient
was treated aggressively for hypertension
and hypercholesterolaemia (a risk factor for
Figure 4 atherosclerosis) with dietary advice and
Diagram of cross-section medication including cholesterol lowering
through lower pons drugs and aspirin. Six months later there has
showing relationship of been a slight improvement in his condition
sixth and seventh cranial although he remains unable to meet the
nerve nuclei and fascicles requirements for driving.
36 December 1, 2000 OT
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Module 2 Part 12
The field loss is to the left consistent with a
CASE 5 visual pathway or cortical lesion on the
right side, behind the chiasm. The macular
A 74-year-old retired County Council 3. Where is the lesion and what is the sparing is the critical localising feature
workman presented to an optometrist after likely underlying pathology? suggesting that the visual cortex serving the
noticing that his vision had reduced. He had 4. Would cataracts or amblyopia in the macula (occipital tip) is spared (i.e. the
never visited an optometrist before, but was left eye affect the visual fields? middle cerebral artery is intact) whilst the
using a pair of his late wife s glasses. 5. What tests would help to assess the visual cortex serving midperipheral and
There was some difficulty in examining foveal function? peripheral fields (mesial surface of the
the patient due to severe spondylosis of the occipital lobe) have been compromised.
neck from ankylosing spondylitis and Answers These are supplied by the middle cerebral
apparent illiteracy, but a refraction of right 1. Does the patient have glaucoma? and posterior cerebral artery respectively,
+1.50/+1.00 x 90, left +2.00 DS gave an No. Glaucoma is a diagnosis reached by suggesting that this patient has experienced
approximate acuity of 6/12 right, 6/24 left. considering several factors including the occlusion of his right posterior cerebral
Non-contact tonometry gave a reading of intraocular pressure, the integrity of the artery, possibly during his illness two-three
22 mmHg right, 26 mmHg left. The red retinal nerve fibre layer, the optic disc years earlier (which may have been a
reflexes were poor and the optometrist neural rim (and cup extent if neural rim is stroke). Smoking is a particular risk factor
was unable to visualise the fundus on being lost) and visual fields (dependent on for all kinds of vascular problems and poor
ophthalmoscopy. She referred the patient to the nerve fibre integrity). However, healthcare suggests that hypertension and
an ophthalmologist for further assessment glaucoma can be diagnosed from the hypercholesterolaemia need to be excluded.
re glaucoma and cataracts. assessment of the optic disc alone, as visual
There were no previous notes available in field changes are not usually evident until 4. Would cataracts or amblyopia in the
the clinic and a routine visual field was substantial changes have occurred to the left eye affect the visual fields?
performed prior to clinical assessment as disc. Cataracts reduce perceived brightness but
shown in Figure 5. The patient stated that Although this patient has high the relatively good acuity suggests that
he had a  cast in the left eye as a child, but intraocular pressure, there is no apparent they are not seriously interfering with vision
had not noticed any problems with his damage to the optic discs and the visual in this patient. In other cases, severe
vision. He said that he had been  a fields appear not to show any defects cataract and amblyopia may both affect the
sharpshooter in the army until about 2-3 consistent with glaucomatous field loss. The absolute values of the test but the relative
years earlier, when he had been admitted to diagnosis in this case is of ocular loss of sensitivity in the visual field of each
hospital with an illness which had  knocked hypertension but he has a risk of about 10% eye individually should be able to show
him off his feet for a few weeks. He took no per year of progression to outright glaucoma visual defects clearly. In this instance, with
regular medication, smoked roll-up cigarettes and will require yearly assessment to ensure dense field defects, the problem should be
and drank around 2 pints of beer daily. that this does not occur. easy to identify. The history of good vision
Physical examination showed a thin and in the army previously cannot be relied
frail gentleman with severe cervical 2. What do the visual fields show upon unless corroborated by a reliable
spondylosis and deep nicotine staining of (Figure 5) and is this consistent examiner in writing. Marksmen use their
the fingers of the right hand. Goldman with glaucoma? right eyes for sighting and even a relatively
tonometry was 20 mmHg right, 24 mmHg The fields show a left homonymous dense amblyopia in the left may be missed
left with moderately deep anterior hemianopia with sparing of the left half of completely!
chambers, open irido-corneal angles and no the macular fields. This appearance is not
pupil defects. There was marked nuclear consistent with glaucoma which typically 5. What tests would help to assess the
sclerotic cataract in both eyes, worse in produces arcuate scotomata arising from the foveal function?
the left, but the optic discs appeared disc (=blind spot on fields). The defects Foveal function is assessed by a variety of
normal with good neural rims and small, associated with glaucoma are independent measurements including acuity, colour vision
non-glaucomatous cups of 0.2. There was in each eye. Disc pathology (including (including Ishihara colour charts) and
mild retinal pigment epithelial changes in glaucoma) would therefore be centered central fields. Specific tests include the
both maculae, but clinical assessment around the blind spot and would not ability to see a red laser aiming dot when it
showed no visual defect arising from this. specifically spare the macular field. These is focused on the fovea and the Watske-
fields are congruous between each eye and Allen test where a slit lamp beam is
Questions observe the midline based on fixation, centered on the fovea and the subject is
1. Does the patient have glaucoma? consistent with CNS pathology. asked whether it is complete or whether
2. What do the visual fields show there is a central break or distortion
(Figure 5) and is this consistent with 3. Where is the lesion and what is the consistent with abnormality, failure or loss
glaucoma? likely underlying pathology? of the fovea (e.g. in macular oedema or
macular hole).
Figure 5 Visual fields of patient of the patient
The patient proceeded to left cataract
surgery which improved acuity to 6/12
unaided at first postoperative visit. He
seemed pleased with the result although the
field loss remained. He defaulted from a
second follow-up appointment. His GP
visited him at home and wrote that the
patient has declined further ophthalmic
attention, as he is  most satisfied with his
position .
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Multiple choice questions - Please note there is only ONE correct answer
Neurology and the eye - Case histories
1. Which one of the following medical 5. Which one of the following a. Lower Motor Neurone involvement of
conditions is a likely cause of a statements is correct? the seventh nerve will result in facial
retinal haemorrhage? Parasympathetic anisocoria hemiparesis.
a. Diabetes mellitus is most easily seen: b. The seventh nerve passes backwards
b. Diabetes insipidus a. in dim indoor light from its nucleus
c. Clotting factor 8 deficiency (von b. in bright indoor light c. Anatomically, the seventh nerve is in
Willebrand s disease) c. in daylight close proximity to the sixth nucleus
d. Platelet deficiency d. at night-time d. Pathology of the seventh nerve will
result in deafness
2. Which one of the following 6. Which one of the following
statements is incorrect? statements is correct? 10. Which one of the following
Patients with myaesthenia gravis: With regard to glaucoma: statements is incorrect?
a. Have an increased risk of other a. An intraocular pressure of more than a. Internuclear ophthalmoplegia may be
autoimmune diseases 40mmHg alone is diagnostic of mimicked by myaesthenia gravis
b. Have antibodies against acetylcholine glaucoma b. Multiple sclerosis is a cause of
receptors in the end-plates of sensory b. Can be diagnosed from assessment of internuclear ophthalmoplegia
nerve fibres the optic disc alone c. Pupil abnormalities are a common
c. May require surgery to control disease c. Is unlikely to be severe if the visual feature of internuclear
d. Are likely to present initially to an fields are unaffected ophthalmoplegia
eye specialist d. 1% of ocular hypertensives will d. The pupils are normal in myaesthenia
progress to outright glaucoma gravis
3. Which one of the following
statements is correct? 7. Which one of the following 11. Which one of the following
Patients with multiple sclerosis: statements is incorrect? statements is incorrect?
a. Are more likely to suffer with In optic neuritis: a. In children, 10% of sixth nerve palsies
episcleritis a. There is usually disc swelling, are attributable to neoplasm if trauma
b. May improve their prognosis with hyperaemia and haemorrhages is excluded
aggressive immunosuppression during b. There may be macular exudates b. 40% of the sixth nerve cell bodies
acute attacks (relapses) c. The disc may be normal project to the contralateral medial
c. May suffer peri-ocular pain during d. There may be an associated rectus
relapses alteration in CSF composition c. Multiple sclerosis is a cause of sixth
d. Often become acutely photophobic nerve palsies
with acute optic neuritis 8. Which one of the following d. Disc swelling and peripapillary
statements regarding uveitis is haemorrhage are early features of
4. Which one of the following incorrect? raised intracranial pressure
statements is incorrect? a. Uveitis can affect pupil movements
a. A pupil sparing third nerve palsy is b. Uveitis is associated with multiple 12. Which one of the following
likely to be due to a compressive sclerosis statements is correct?
lesion c. Topical steroids reduce the a. Macular sparing in occipital CVA
b. Consensual eye movements are aided inflammation that occurs in (stroke) suggests involvement of the
by sixth nucleus projections to the uveitis middle cerebral artery
contralateral medial rectus d. Miotics should be prescribed to b. Cataracts rarely give rise to formal
c. An esotropia may be caused by a prevent posterior synaechiae visual field defects
sixth nerve palsy c. Visual acuity is usually significantly
d. A third nerve lesion with early 9. Which one of the following reduced in a CVA affecting the tip of
involvement of the pupil is likely to statements regarding the seventh the right occipital lobe
be compressive nerve is incorrect? d. A left hemianopia may be caused by a
glaucomatous loss of the temporal
right optic disc
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ABOUT THE AUTHOR
It should be completed and returned to:
Adrian Parnaby-Price is a
CPD Initiatives (NOE12),
Consultant in Ophthalmic Surgery
OT, Victoria House, 178 180 Fleet Road, Fleet,
at St George s Hospital, London
Hampshire, GU13 8DA by January 10, 2001.
38 December 1, 2000 OT
www.optometry.co.uk