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4 Causes of 1st order horners

1. Wallenberg syndrome
2.Stroke
3. Demyalinating disease of cervical spine
4. Cervical disc dz

1

Name 2 Cause of 2nd order horner

1. Apical lung ca
2. Thor ao aneurysm

2

Name 3 causes of 3rd order horners

1. Ica dissection
2. Cav sinus thrombosis
3. Cluster ha

3

Whats wallenberg syndrome?

Infarct of lateral medulla 2/2 pica stroke affects ipsilateral horners (1st order)

4

What male color blindness called

Deuteranomalous

5

What are the normal limits of a visual field?

60 degrees sup
60 nasal
75 infrior
110 temporal

6

What does homonomous mean?

Is it on the same side of the vertical meridien?

7

What are the two lhon genes

11778 worse prog
14484 better prog

8

Whats behrs syndrome?

Infant hereditary optic neuropathy autosomal recess
Mr
Incontinence

9

What is tensilon?

Ach-ase inhibitor
Therefore puts ach there

10

Whats lambert eaton?

Mg-like syndrome
But problem is no release of ach from presynaptic terminal

11

How does lambert eaton present?

Fatigue in the am that gets better over the day

12

What malignancy is lambert eaton associated with?

Sc lung ca

13

Whats kerns sayre?

Cpeo
Pigmentary retinopathy
Heart block

14

Order of muscles effected by thyroid

Imslo

15

Whats oculopharyngeal dyatrophy?

Cpeo w dysphagia in french canadians

16

Whats the #1 modifiable risk factor for thyroid orbitopathy?

Quit smoking

17

Whats the pathway of a horizontal saccade if you want to look right?

Left frontal eyefields--> parietal eye fields--> superior colliculus of midbr--> pprf that connects cn3 and 6

18

What part of the brain are you testing w an okn drum?

Parietal lobe bc youre checking the horizontal saccade pathway

19

Whats the pathway for vertical saccades?

Frontal eye fields--> ipsilateral rostral interstitial nucleus of the mlf

20

Whats the interstitial nucleua of cajal?

Integrates the saccadic signals for upgaze and downgaze

21

Name 4 causes of slow saccades

1)pprf lesion
2) ino
3) anticonvulsants
4) paraneoplastic sx

22

What causes an ino?

Disruption of mlf extending from midbr to pons

23

What are two causes of ino

Ms
Stroke

24

How does ino present?

Ipsilateral adduction deficit w contralateral abduction nystagmus

25

Whats one and a half syndrome? (Right side)

Right mlf = cannot adduct od
Ipsilateral cn6 or pprf= cannot abduct od and yoke cannot adduct os bc pprf controls total gaze to the right

All thats left is contralateral cn6 abduction

26

What does "supranuclear" mean?

Involuntary control centers in the cortex

27

What would a stroke of the right frontal eye fields cause?

Eyes deviate toward the lesion (to the right) bc of unopposed signaling from left frontal eye fields

28

What are the 4 signs of dorsal midbrain syndrome?

1) upgaze palsy
2) colliers sign(bl lid retraction)
3) light near dissociation
4) convergence retraction nystagmus (on attempt to look up eyes nystagmus)

29

Whats the ddx of light near dissociation?

1) adies pupil (decr parasymp inn to pupil)
2) syphillis
3) dorsal midbr syndrome

30

What are 4 findings in psp?

1) slow saccades esp DOWNwARD
2) rigidity
3) dysphagia
4) apraxia of lid opening ( cant open eyes)

Fatal in 6 yrs

31

What are the findings in convergence spasm?

Miosis
Blurry vision
Et

Rx w cyclogyl and weak minus lenses

32

Whats the 1 finding in convergence insufficiency?

**Exotropia greater at near than distance of at least 10 pd **
Cannot bring eyes in

Rx w pencil pushups

33

Whats a skew deviation?

A hyper or hypo that doesnt fit into cn4 palsy. Its caused by vestibular issue

34

Whats miller fisher syndrome?

Variant of guillian barre
Goes from top down
Causes cn6 palsy
Anti Gq1b

35

Whats pendular nystagmus?

Both phases of the nystagmus are slow

36

Whats jerk nystagmus?

Type of nystagmus that has a slow and fast phase

37

Whats infantile nystagmus syndrome?o

Starts in first mnths of life
Can be jerk or pendular
Picks up w monocular occlusion
Can treat w kestenbaum procedure

38

Whats latent nystagmus?

Occurs w infantile et
Quick phase toward the fixing eye

39

4 causes of downbeat nystagmus

1) ms
2) lithium
3) arnold chiari (malformation of posterior fossa allows downward herniation thru foramen magnum)
4) mag deficiency

40

What causes upbeat nystagmus?

Midbr or cerebellar lesion
Ms
Tumor

41

What type of nystagmus does ms cause?

Any type!!'
Bc there can be demyelinating lasions in any part of brain

42

What area of brain does torsional nystagmus localize to?

Ponto-medullary junction

43

Where does see saw nystagmus localize to?

Sella

44

Whats periodic alternating nystagmus and how to treat?

Nystagmus switches directions q minute.
Seen in ms
Rx w baclofen

45

Where does ocular bobbing localize to?

Pons

46

Whats see saw nystagmus?

One eye goes down and the other goes up

47

What drugs can you use for oscillopsia from nystgmus?

Baclofen
Gabapentin
Memantine

48

Whats opsoclonus (very testable)

Saccadomania!!

49

What are causes of opsoclonus?

Infectious
Paraneoplastic (neuroblastoma in kids!!!!)
Drugs

Get mri

50

Whats superior oblique myokymia?

Spasm of cn4

51

How do you treat sup oblique myokymia? 3 possibilities

Propranolol
Ganapentin
Superior oblique tenectomy

52

What should u suspect w pain and cn3 signs?

Pcom aneurysm

53

Whats webers syndrome

Cn3 w contralat hemiparesis

54

Whats benedicts syndrome

Cn3 palsy w contalateral tremor

55

Whats the ddx of multiple cn palsy?

Pituitary apoplexy
Cav sinus
Growing tumor
Tolosa hunt(inflamm of cav sinus)

56

How does pituitary apoplexy present?

Labile bp
Adrenal insuff
Give hydrocortisone immediatly

57

Findings in iih?

Opening pressure >250 mm h2o
Normal neuroimaging
Empty sella
Nausea
Enlarged bs
Papilledema
Tinnitus
Choroidal folds

58

How do you work up iih?

Check mri and mrv ( thrombosis of cerebral sinus) and LP

59

How would a lesion of superior optic disc present of vf?

Inf altitudnal defect

60

How does a lesion of the papillomacular bundle present on vf?

Cecocentral scotoma or central scotoma

61

How does infarct of nfl present on vf?

Arcuate scotoma

62

Whats cecocentral scotoma?

Connecta blond spot to center

63

Whats the most common cause of an altitudnal defect on vf?

Naaion

64

Whats the ddx of enlarged bs (4 things)

1. Mewds
2. Papilledema
3. Od drusen
4. Tilted nerve

65

Most common cause of cecocentral or central scotoma?

Compressive lesion
toxic
nutritional
optic neuritis

66

Most common cause of superior alt defect?

Optic neuritis

67

Whats the ddx of bl optic neuropathy 4 things

1) nutritional
2) toxic
3)lhon
4) compressive

68

What types of vf do you think "its an on problem?"

Cecocentral scotoma
Central scotoma
Altitudnal
Arcuate

69

Most common vf in naaion?

Inferior altitudnal defect

70

If the defect respects the vertical meridian what does that mean?

Defect is behind chiasm

71

Vf respects the horizontal meridian what does that mean?

Its an on problem

72

Whats the ddx of atypical optic neuritis?

Lyme
Sarcoid

73

What to think of w papilledema?

Tumor
Pseudotumor

74

What imaging study to get w bitemporal hemianopsia?

Mri w gad

75

Why get gad on a scan?

Enhances tumors

76

What kind of vf do you get w willibrands knee lesion?

Unilat complete scotoma and otherside temporal scotoma (bc of crossing nasal fibers)

77

If you get a unilateral temporal defect respexting vertical midline wheres the defect?

Pituitary tumor until proven otherwise!

78

Where is meyers loop?

Temporal lobe

79

Where does inferior quadrantopia localize to?

Parietal lobe

80

You see left sides bilat homon hemianopsia which tract effected and which eye has apd?

Right optic tract
Left apd

81

What does incomplete third mean?

Not all muscles involved

82

How do you charterize cn3 palsy?

1. Complete vs incomplete
2. Pupil involved vs not involved

83

What causes abbarent regeneration of cn3?

Tumor
NOT vascular

84

How is superior rectus innervated?

Contralat cn3 nuc

85

How is levator innervated?

Single midline subnucleus innervates both levators

86

Name 4 causes of pupil sparing 3rd

1) vascular
2) mg
3) gca
4) ms

87

What innervates so?

Contralateral cn4 nucleus

88

Whats in the cavernous sinus?

3,4,51,52,6,ica w sympathetics on it

89

Whats the three step test

1) which is hyper
2) gaze
3) tilt test

90

Name 3 causes of cn4 palsy?

1) mg
2) trauma
3) ichemia

91

What can a lesion of the clivus bone cause?

Cn6 palsy

92

Whats gradinegos syndrome

6th n palsy from mastoiditis

93

How does cn6 palsy get worked up if pt less than 60 w no ischemia signs?

Mri look for cav sinus tumor, compression, ms

94

Whats the finding when u put cocaine in horners person?

Normal pupil dilates
Abnormal pupil does not dilate

95

Whats millard grubler syndrome?

6th nerve nuclear syndrome- lesion in pons
Ipsilat 6th
contralateral hemiplegia
ipsilateral facial palsy

96

What happens when u put apraclonidine in horners

Normal pupil does not dilate
Abnormal pupil does dilate

97

Ddx of choroidal folds

Tao
IIH
Posterior scleritis

98

How is the mr lr io ir innervated?

Ipsilateral cn3 nuc

99

Triad of spasmus nutans and w/u

1) low amp high freq nystagmus
2) head bobbing
3) torticollis

Get mri

100

What % of pple will have naion in OThER eye?

15%

101

What % of pple w optic neuritis have pain?

90%

102

Whats a defining feature of congenital nystagmus?

Increase slow phase velocity over time

103

whats the finding in a CN6 NUCLEUS deficit?

1) ipsilateral gaze palsy- eg right 6th nuc out = unable to look right both eyes
2) ipsilateral facial palsy

104

what type of nystagmus has a VF deficit?

see saw bc localizes to sella

105

what type of nystagmus with defect of central tegmental tract? (midbr and pons)

oculopalatal myoclonus

106

a lesion to the MLF can cause INO and what else?

skew deviation

107

which cn palsy can you get in IIH?

CN6- causes horiz diplopia 2/2 incr intracran pressure. They should not get vertical diplopia bc cn3 should not be involved.

108

what are 2 types of vf defects you can get in IIH?

1) enlarged BS
2) arcuate glaucoma-like defects

109

an you get an APD in IIH?

Yes, if papilledema is asymmetric

110

what type of nystagmus do you get with lesion of the central tegmental tract (runs from pons to medulla)?

oculopalatal myoclonus

111

early male balding, difficulty releasing grip, cardiac conduction defects- which disease?

myotonic dystrophy

112

what else can cause optic neuritis besides MS?

sarcoid, lupus, syphillis
this is "atypical" ON- consider it esp when there florid papilledema w heme

113

who gets ophthalmoplegic migraines and how does it present?

children
migraine w cn3 palsy

114

why can a right INO cause a right hyper w right incyclotorsion (in addition to adduction deficit on that side?)

it causes a skew deviation b/c the MLF also gets vestibular input from the ear

115

if a young woman comes in c/o scotoma w/o retinal dz or onh dz, but on hvf has an enlarged BS, how should you work up?

mfERG
could be IBS (idiopathic blind spot syndrome) may show focal retinal problem

116

what causes oculopalatal myoclonus?

brainstem stroke. The nystagus usually presents years after the stroke

117

pt presents with normal eye exam and numb chin, what should you ask about?

h/o of cancer-
malignancies associated with mental neuropathy are lymphoma and breast ca

118

injection of intracameral moxifloxacin at the end of cataract surgery has been asscoaited with what type of inflammation?

TASS

119

when there is ONH swelling, whats the next question you should ask?

are there disc hemorrhage
hemorrhages- most likely NAION (infarction of the ONH)
No heme- more likely optic neuritis

120

optic neuritis- how long does it take to recover to baseline vision?

85% return to baseline within 3 months

121

what would make optic neuritis atypical?

bilateral
age >50
no pain

122

if you have optic neuritis w no white matter lesion- whats the chance you will dev MS in 15 years?

25%

123

if you have optic neuritis and 1 white matter lesion whats the chance you will dev MS in 15 years?

75%

124

what should you never give to a pt w optic neuritis?

oral prednisone

125

what MUST you have on exam to dx NAAION?

ONH swelling (hyperemic)

126

Whats the visual prognosis in NAION?

1/3 get better, 1/3 stay the same and 1/3 get worse

127

whats the typical vision in NAION?

20/40
if they are LP or worse think AION

128

Why does disk and risk cause NAION?

crowding of structures in ONH, decreased axoplasmic flow

129

what type of VF defect in NAION?

inferior alt defect or central scotoma

130

NAION in one eye whats the chance of getting it in the other eye?

20%

131

how do you treat AION if they have visual loss

1g solumedrol x 3 days
followed by prednisone 1mg/kg/day

132

how do you treat AION if they don't have visual loss?

prednisone 1mg/kg/day and order TA biopsy (increased your yield by 5%)

133

whats the ddx of bilateral ONH edema?

malig HTN- headache, double vision (6th), check BP
ONH drusen->do bscan
papilledema-

134

papilledema VF

Enlarged BS

135

pale nerve must rule out infiltrative dz or mass cannot say naion wo seeing onh edema

n/a

136

if pt c/o worsening vision over months w pale nerve and decr color vision whats next step?

image

137

how does LHON present? who gets it

mitochondrial
high-school aged male
bilateral hyperemic discs
gradual loss of vision in one eye then the other
may get worse symptoms with hot bath or exercise (uthoff phenomenon)
vision 20/200
bilateral central or cecocentral scotoma

138

which LHON gene has better/worse prognosis

14484- better
11778- worse

139

What do you do w pupil involving 3rd?

Image

140

What do you do in a complete pupil sparing 3rd?

Nothing

141

What do you do in an incomplete (not all muscle effected) and pupil sparing 3rd?

Image

142

Where does benedicts localize to?

Redn in midbr

143

Where does claude sx (3rd w ataxia) localize to?

Area between red n and cerebral peduncle

144

Where does webers (3rd w hemiparasis) localize to?

Cerebral peduncle (top of micky ear) in midbrain

145

Blown pupil who walks into office and cn3 otherwise fine likely dx

Adies

146

after damage to the nnfl how long does it take for ON atrophy to appear?

1 month

147

what plt count is suspicious for GCA?

>400,000

148

where is the pprf located?

pons

149

wheres the interstitial nuc of cajal?

midbrain

150

according to the ontt, what % of pts w ON present with PAIN

92%

151

whats the biggest difference between papilledema from mass and onh swelling from other causes

papilledema tends to have good vision until late in the course.
ONH edema from other causes tends to have shit vision right from the start

152

whats a good way of distinguishing between foster kennedy and pseudo foster kennedy?

foster kennedy- papilledema due to a mass will have a gvf of EBS 2/2 papilledema
pseudo foster kennedy 2/2 sequential naion should have gvf looks like naion (ie inferior arcuate)