Neuro-Ophthalmology (Visual Pathway, Pupillary Reflexes, Optic Nerve, Gaze) MCQs

Ophthalmology · 89 free questions with answers & explanations.

1. A 35-year-old woman presents with subacute visual loss in the right eye, periocular pain on eye movement, and a relative afferent pupillary defect (RAPD). MRI shows enhancement of the right optic nerve. The most likely diagnosis is:
2. A patient suffers a stroke affecting the right optic tract. The expected visual field defect is:
3. A 70-year-old man with giant cell arteritis presents with sudden painless visual loss and a pale, edematous optic disc with disc sector infarction visible on fundus examination. What distinguishes this condition from the non-arteritic form?
4. In the swinging flashlight test, both pupils constrict when light shines in the normal left eye, but the right pupil paradoxically dilates (re-dilates) when light is swung to it. This indicates:
5. A patient develops internuclear ophthalmoplegia (INO) with adduction failure of the right eye and nystagmus of the abducting left eye on left gaze. The lesion is located in:
6. A 25-year-old woman is referred for bilateral disc swelling found incidentally. She has headache on bending but no other focal neurological deficits. Visual acuity is 6/6 bilaterally. Visual fields show enlarged blind spots. She is obese (BMI 38) and on oral contraceptives. MRI brain is normal; MRI venography is normal. LP opening pressure is 34 cm H₂O. What is the most likely diagnosis and recommended first-line pharmacological treatment?
7. A 70-year-old man develops a complete right third nerve palsy with ptosis, a 'down and out' eye, and a dilated, non-reactive right pupil. CT and MRI angiography reveals a posterior communicating artery aneurysm on the right. Why does aneurysmal CN III palsy characteristically involve the pupil first?
8. A 50-year-old man with a history of heavy smoking presents with ipsilateral ptosis, miosis, and anhidrosis of the face, with a small palpable lymph node above the left clavicle. What is the most likely anatomical cause of the Horner's syndrome in this patient?
9. A 65-year-old man presents with bilateral progressive visual field loss affecting only the upper visual fields ('altitudinal' loss), with normal optic disc appearance. OCT shows thinning of the inferior macular ganglion cell layer. Which condition is most consistent with bilateral inferior arcuate visual field loss respecting the horizontal meridian?
10. A 45-year-old man presents with painless progressive bilateral disc pallor over 6 months. There is centrocaecal scotoma in both eyes on Humphrey visual field analysis. He denies tobacco or alcohol use and is not on any medications. Mitochondrial DNA analysis reveals an 11778 G→A point mutation. The diagnosis is:
11. A 32-year-old woman presents with sudden onset diplopia and right ptosis. Examination reveals right eye with mydriasis, abducted and slightly depressed position, with failure of adduction, elevation, and depression. The light reflex is absent in the right eye. CT brain is unremarkable. MRI with gadolinium is urgently requested. The MOST likely diagnosis and the key MRI finding expected is:
12. A 68-year-old man with a 3-day history of progressive visual loss in the right eye, initially worse on waking. The right optic disc appears swollen with splinter hemorrhages. ESR is 85 mm/hr. CRP is elevated. Temporal artery biopsy is planned. Before the result returns, the MOST critical immediate management step is:
13. A patient has a lesion in the right frontal eye field (FEF, Brodmann area 8). Acutely, the eyes deviate to the RIGHT. After 2 weeks, the deviation resolves. What is the mechanism underlying the ACUTE contralateral gaze deviation (towards the lesion side)?
14. A 40-year-old woman presents with progressive bilateral visual loss, optic disc pallor, and visual field showing cecocentral scotomas bilaterally. MRI brain and orbits are normal. Mitochondrial DNA analysis reveals the 11778 G>A mutation in the ND4 gene. Which subunit of the mitochondrial complex is affected in this condition?
15. During a relative afferent pupillary defect (RAPD) examination using the swinging flashlight test, when the light is moved from the normal left eye to the abnormal right eye, which of the following is the CORRECT description of the pupillary response?
16. The ONTT (Optic Neuritis Treatment Trial) demonstrated which key finding regarding long-term visual outcomes and MS risk?
17. A patient with right internuclear ophthalmoplegia (INO) will show which combination of eye movement findings?
18. In Adie's tonic pupil, denervation supersensitivity can be demonstrated using which concentration of pilocarpine, and what is the expected response?
19. A patient with known Foster Kennedy syndrome will show which classic combination on fundoscopy?
20. The NORMAL afferent pupillary defect (RAPD/Marcus Gunn pupil) testing procedure is performed by the swinging flashlight test. A positive RAPD indicates a lesion in which part of the visual pathway?
21. The ONTT (Optic Neuritis Treatment Trial) provided which specific management guideline that changed clinical practice for optic neuritis?
22. A patient presents with a left homonymous hemianopia that is denser inferiorly (inferior quadranopia). The lesion is most likely located at:
23. Leber's hereditary optic neuropathy (LHON) is caused by mitochondrial DNA mutations. The most common primary mutation accounting for approximately 70% of LHON cases in European populations is at position:
24. In internuclear ophthalmoplegia (INO), the lesion is in the medial longitudinal fasciculus (MLF). The affected eye (ipsilateral to the MLF lesion) shows failure of adduction. The characteristic finding in the contralateral abducting eye is:
25. The concept of 'pseudo-Foster Kennedy syndrome' differs from true Foster Kennedy syndrome in that:
26. In a patient with a lesion in the right paramedian pontine reticular formation (PPRF), the expected eye movement finding is:
27. The Foster Kennedy syndrome involves optic atrophy in one eye and papilloedema in the other. In which tumour location is this classically described?
28. Leber hereditary optic neuropathy (LHON) is caused by mitochondrial DNA point mutations. Which of the following is the most common primary mutation?
29. A 32-year-old woman presents with acute painful monocular visual loss, RAPD, and mild disc hyperemia. MRI shows a periventricular white matter lesion. Which clinical trial established the benefit of IV methylprednisolone in this condition?
30. In Horner syndrome, which pharmacological test confirms a preganglionic (second-order neuron) lesion as opposed to a postganglionic (third-order) lesion?
31. A patient with a CN III palsy has a 'down and out' eye with a mid-dilated non-reactive pupil. The MOST urgent investigation to exclude a life-threatening cause is:
32. In Parinaud's dorsal midbrain syndrome, the characteristic finding of light-near dissociation occurs because:
33. The Frisen scale (grades 0–5) is used to document severity of which ophthalmological sign?
34. A patient presents with episodic monocular visual loss lasting 5–10 minutes described as a 'curtain descending from above'. This classic presentation of amaurosis fugax is caused by:
35. The ONTT (Optic Neuritis Treatment Trial) demonstrated that high-dose IV methylprednisolone for optic neuritis:
36. A 55-year-old hypertensive patient presents with sudden painless monocular visual loss with 'curtain coming down from above.' Fundus shows a pale retina with a cherry red spot at fovea. The fovea is spared initially because its nutrition is supplied by:
37. The Pretectal nucleus in the dorsal midbrain mediates the pupillary light reflex via which pathway that explains why cortical blindness (occipital lobe lesion) does NOT abolish the light reflex?
38. A 35-year-old woman with multiple sclerosis develops horizontal diplopia with failure of adduction in the right eye and abducting nystagmus of the left eye. Which gaze position reveals maximal diplopia?
39. Leber's hereditary optic neuropathy (LHON) causes acute/subacute bilateral sequential central visual loss. The most common mitochondrial DNA point mutation responsible is at position:
40. Dorsal midbrain (Parinaud's) syndrome is characterized by all EXCEPT:
41. The ONTT (Optic Neuritis Treatment Trial) fundamentally changed the management of optic neuritis by demonstrating that:
42. In Horner's syndrome, the hydroxyamphetamine (paredrine) test distinguishes central/preganglionic from postganglionic lesions. The pharmacological basis is:
43. A 45-year-old presents with a progressive superior altitudinal visual field defect with cup-to-disc ratio 0.4 and normal IOP. MRI brain is normal. Fluorescein angiography shows non-perfusion in the superior peripapillary region. The most likely diagnosis is:
44. In the dorsal midbrain (Parinaud's) syndrome, the classic triad includes upgaze palsy, convergence-retraction nystagmus, and light-near dissociation. The neural substrate for convergence-retraction nystagmus is:
45. In Leber's hereditary optic neuropathy (LHON), the primary mitochondrial DNA point mutation at position 11778 (ND4 subunit) results in impaired complex I function. The mechanism by which this causes selective retinal ganglion cell death is:
46. A relative afferent pupillary defect (RAPD) indicates reduced afferent light input from one eye relative to the other. RAPD is detected by the swinging flashlight test. A positive RAPD is seen in all of the following EXCEPT:
47. Internuclear ophthalmoplegia (INO) results from a lesion of the medial longitudinal fasciculus (MLF). The MOST common cause of bilateral INO in a young adult is:
48. Leber hereditary optic neuropathy (LHON) classically presents with:
49. A patient develops a 'one-and-a-half syndrome' (conjugate gaze palsy to one side plus ipsilateral internuclear ophthalmoplegia). The anatomical lesion responsible is located in the:
50. In anterior ischemic optic neuropathy (AION), the arteritic form (A-AION due to giant cell arteritis) differs from non-arteritic AION (NA-AION) in which of the following ways?
51. The Marcus Gunn pupil (relative afferent pupillary defect, RAPD) is detected using the swinging flashlight test. A positive RAPD indicates:
52. A 40-year-old woman presents with sudden diplopia on looking to the right. Examination shows right eye abduction weakness with right beating nystagmus when the left eye (intact) adducts. Convergence is preserved. The MOST likely localization is:
53. A 38-year-old woman presents with progressive painless visual loss in the right eye over 3 weeks with a central scotoma. MRI shows a gadolinium-enhancing lesion of the right optic nerve without chiasmal involvement. VEP shows prolonged P100 latency in the right eye. The MOST likely diagnosis is:
54. A 45-year-old woman has an afferent pupillary defect (APD) in the right eye. When a torch is swung from the left to the right eye, the right pupil paradoxically dilates instead of maintaining constriction. Which feature of this sign confirms an optic nerve lesion rather than an anterior segment or retinal cause?
55. A 30-year-old patient with known multiple sclerosis presents with painful loss of vision in one eye, reduced colour vision, and an RAPD. OCT shows retinal nerve fibre layer (RNFL) thinning in the superior and inferior arcuate bundles. MRI reveals a T2 hyperintense lesion in the right optic nerve. Which visual field defect is most characteristic during the acute phase of optic neuritis?
56. A 58-year-old hypertensive man wakes up with sudden painless loss of the superior visual field in his left eye. Fundus examination shows pallid disc oedema in the inferior half of the optic disc and flame haemorrhages at the disc margin. The cup-to-disc ratio is 0.1. This is most consistent with:
57. A patient presents with internuclear ophthalmoplegia (INO). On attempted left lateral gaze, the left eye abducts fully but the right eye fails to adduct. Convergence is intact. Where is the lesion?
58. A 70-year-old woman with jaw claudication, temporal headache, and scalp tenderness presents with sudden painless bilateral sequential visual loss. ESR is 110 mm/hr, CRP is elevated, and temporal artery biopsy shows granulomatous inflammation with giant cells. What is the immediate management?
59. A 35-year-old woman develops sudden severe headache ('thunderclap'), third nerve palsy with a dilated, unreactive pupil (pupil-involving CN III palsy). The most urgent investigation and likely diagnosis are:
60. A patient with a demyelinating lesion at the right medial longitudinal fasciculus (MLF) at the level of the pons would demonstrate which characteristic eye movement abnormality?
61. Foster Kennedy syndrome consists of central scotoma with optic atrophy in one eye and papilloedema in the fellow eye. The most common cause is:
62. A 35-year-old woman with MS presents with painful loss of vision in the right eye over 3 days. Visual acuity is 6/60 right eye, 6/6 left. There is no disc swelling on fundoscopy. Which sign, if present, strongly supports the diagnosis of retrobulbar optic neuritis rather than papilledema?
63. A patient presents with a right third nerve palsy (ptosis, mydriasis, adduction deficit). MRI brain shows a 7 mm aneurysm at the posterior communicating artery (PCoA)-ICA junction. The mydriasis in this case is best explained by:
64. Internuclear ophthalmoplegia (INO) is characterized by which specific eye movement abnormality and its pathological basis?
65. A 45-year-old presents with sudden onset of right homonymous hemianopia with macular sparing. MRI shows a lesion in the left occipital lobe. The macular sparing is best explained by:
66. A patient has ptosis, miosis, and anhidrosis of the ipsilateral half of the face. This Horner syndrome involving facial anhidrosis suggests the sympathetic lesion is located at which level?
67. Papilloedema differs from optic disc oedema due to optic neuritis in which characteristic?
68. Internuclear ophthalmoplegia (INO) is characterised by which clinical finding on horizontal gaze testing?
69. One-and-a-half syndrome is caused by a lesion at which location?
70. In Adie's tonic pupil, the dilated pupil shows which characteristic response to pharmacological testing?
71. A relative afferent pupillary defect (RAPD) is detected on the swinging flashlight test. This indicates a lesion in:
72. A patient with a lesion in the right paramedian pontine reticular formation (PPRF) will show:
73. A patient presents with bilateral temporal hemianopia. MRI shows a pituitary macroadenoma compressing the optic chiasm. The decussating fibres at the chiasm carry which visual field information?
74. A 50-year-old diabetic presents with sudden right eye ptosis and divergent squint. On examination, the pupil is mid-dilated and non-reactive. Which cranial nerve is affected and what is the anatomical reason for pupil involvement in this case?
75. A 70-year-old woman presents with sudden visual loss in the right eye. The disc appears segmental oedema with pallor, flame haemorrhages at the disc, and ESR is 85 mm/hr. She has jaw claudication and scalp tenderness. What is the MOST URGENT investigation and treatment?
76. A patient has a right homonymous hemianopia with macular sparing. Where is the most likely site of the lesion?
77. A 28-year-old woman has acute painful optic neuritis. Visual field shows a cecocentral scotoma. MRI of the brain reveals 2 white matter lesions at the corpus callosum perpendicular to its surface (Dawson's fingers). The MOST appropriate immediate management is:
78. A 70-year-old man wakes up with painless sudden loss of vision in one eye. Fundus examination shows disc oedema, splinter haemorrhages at the disc, and a pale swollen optic disc. Visual field shows an altitudinal defect. The MOST likely diagnosis is:
79. The swinging flashlight test in a patient with a right relative afferent pupillary defect (RAPD) shows:
80. A 45-year-old woman has bitemporal hemianopia on Goldman perimetry. MRI shows a suprasellar mass. The visual field defect results from compression of which structure?
81. A 32-year-old woman presents with recurrent episodes of painful red eye, photophobia, and blurred vision. Slit-lamp shows fine keratic precipitates (KPs) in a triangular distribution (Arlt triangle) on the inferior corneal endothelium, cells and flare in the anterior chamber, and a small posterior synechia. Systemic workup reveals bilateral hilar lymphadenopathy on chest X-ray. The most likely diagnosis is:
82. A 45-year-old man presents with bilateral panuveitis, poliosis, vitiligo, alopecia, and hearing impairment. He also reports a history of meningism two months ago. Which condition best explains this constellation of findings?
83. A 50-year-old man develops ptosis and diplopia. Examination reveals complete ptosis of the right eye, the globe is deviated down and out, the pupil is dilated and fixed at 6 mm, and there is no light reflex. Which structure is most likely compressed?
84. A 25-year-old woman presents with progressively worsening headache, transient visual obscurations, and horizontal double vision. She is obese with a BMI of 38. Fundoscopy shows bilateral disc oedema. MRI brain and MR venography are normal. Lumbar puncture reveals an opening pressure of 38 cm CSF. The most appropriate initial management is:
85. A 60-year-old hypertensive man wakes up with sudden loss of vision in the right eye. Visual acuity is counting fingers. There is a relative afferent pupillary defect (RAPD) on the right. Fundoscopy shows an oedematous, pale disc with flame-shaped haemorrhages at the disc margin. The most likely diagnosis is:
86. Leber hereditary optic neuropathy (LHON) exhibits maternal inheritance. The primary mitochondrial DNA mutation responsible for >90% of LHON cases are point mutations at positions:
87. Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus (MLF). In left INO, which gaze abnormality is expected?
88. In Miller Fisher syndrome (MFS), the triad of ophthalmoplegia, ataxia, and areflexia is associated with anti-GQ1b antibodies. GQ1b ganglioside is particularly concentrated at which anatomical location explaining the ophthalmoplegia?
89. A lesion of the right paramedian pontine reticular formation (PPRF) causes: