Neuro-opthalmic Disease

Question 1

What are some causes of optic nerve defects?

Answer 1

1. Ischaemic optic neuropathy
2. Optic neuritis
3. Tumours (rare)

Question 2

What is the most common cause of optic neuritis?

Answer 2

Multiple sclerosis

Question 3

What are the classic features of optic neuritis?

Answer 3

1. Pain on eye movement
2. Colour desaturation
3. Central scotoma
4. Progressive unilateral vision loss

Question 4

What visual defect does an optic nerve lesion cause?

Answer 4

Unilateral (monocular) visual loss

Question 5

What does optic atrophy look like on fundoscopy?

Answer 5

Pale optic disc

Question 6

What visual defect is caused by an optic tract lesion?

Answer 6

Contralateral homonymous hemianopia

Question 7

What field defect is caused by a lesion at the optic chiasm?

Answer 7

Bitemporal hemianopia

Question 8

What is the most common cause of chiasmal compression?

Answer 8

Pituitary tumour

Question 9

What visual defect is caused by a temporal lobe (Meyer’s loop) lesion?

Answer 9

Contralateral superior quadrantanopia (“pie in the sky”)

Question 10

What visual defect is caused by a parietal lobe lesion?

Answer 10

Contralateral inferior quadrantanopia (“pie on the floor”)

Question 11

What visual defect results from a lesion in the occipital cortex?

Answer 11

Contralateral homonymous hemianopia with macular sparing

Question 12

What investigation is used to assess suspected optic chiasm lesions?

Answer 12

MRI head

Question 13

What does ‘homonymous hemianopia’ mean?

Answer 13

Loss of the same half of the visual field in both eyes

Question 14

What does ‘hemianopic’ mean?

Answer 14

Half the visual field is affected

Question 15

What does ‘quadrantanopic’ mean?

Answer 15

A quarter of the visual field is affected

Question 16

A young woman wakes with a world turned grey. One eye blind, pain dancing behind it, and colours leached from reality.

Which horseman of neurology rides here?

Answer 16

Optic neuritis (often MS)

Question 17

The left eye sees darkness, the right sees light. A lonely, unilateral fall into shadow

Where lies the damage?

Answer 17

Optic nerve (left-sided lesion = left-sided blindness)

Question 18

What visual field defect results from a left optic nerve lesion?

Answer 18

Complete left-sided (ipsilateral) monocular visual loss

Question 19

What is the most likely visual defect caused by a right optic tract lesion?

Answer 19

Left homonymous hemianopia

Question 20

What condition causes arteritic ION?

Answer 20

Giant cell arteritis (temporal arteritis)

Question 21

What is the typical presentation of ION?

Answer 21

Sudden, painless visual loss

Question 22

What artery is occluded in ischaemic optic neuropathy (ION)?

Answer 22

Posterior ciliary arteries

Question 23

What causes the artery wall to occlude in arteritic ION?

Answer 23

Inflammation and thickening of the vessel wall

Question 24

What clinical signs suggest GCA is involved in ION?

Answer 24

Headache, scalp tenderness, and enlarged temporal arteries

Question 25

What is the management for ION caused by GCA?

Answer 25

High-dose steroids

Question 26

What does fundoscopy show in ION?

Answer 26

Pale, swollen optic disc

Question 27

Painful ocular movement suggests a diagnosis of what?

Answer 27

Optic neuritis

Question 28

A 75-year-old female presents to Accident & Emergency complaining of a loss of vision in her right eye. She reports waking up this morning with no vision in her right eye and a headache. She has a history of undiagnosed painful joints and mentions several occasions in the past few weeks where her vision has temporarily ‘gone dark’ On examination, you note that her visual acuity is reduced to light perception and her right pupil displays a relative afferent pupillary defect. Which clinical feature suggests a diagnosis of ischaemic optic neuropathy?

Answer 28

Swollen optic disc

Question 29

What are the 2 types of ION? and explain their differences

Answer 29

(1) Arteritic AION (usually due to giant cell arteritis): = Typically, painless vision loss = scalp tenderness, jaw claudication, fatigue = Pale, swollen optic disc = treat urgently with steroids (2) Non-arteritic AION (more common): = It can be painless or mildly painful, especially around the eye = Sudden visual loss, often on waking = diabetes, hypertension = Also shows pale, swollen optic disc

Question 30

'MS, young, painful'

Answer 30

Optic neuritis

Question 31

'older, vascular, painless'

Answer 31

Ischaemic Optic Neuropathy

Question 32

What would an examination of optic neuritis show?

Answer 32

1. Pain on eye movement 2. ↓ visual acuity, ↓ colour vision (red desaturation) 3. RAPD 4. Central scotoma 5. Optic disc may be normal or swollen. 6. Often linked to multiple sclerosis

Question 33

A 70-year-old woman presents with the sudden onset of painless vision loss in her right eye. Her past medical history is significant for atrial fibrillation, hypercholesterolaemia, and hypertension On examination, the left optic disc is oedematous with a blurred disc margin, small flame-shaped haemorrhages, and a small cup-to-disc ratio. There is a relative afferent pupillary light defect (RAPD) present. What is the pathophysiology of the underlying condition?

Answer 33

Vascular insufficiency to the optic nerve = diagnosis of anterior ischaemic optic neuropathy

Question 34

A 55-year-old man presents to the eye emergency clinic with sudden vision loss in his left eye. He is very anxious and reports that he has previously seen his GP with issues of his vision darkening for a few minutes before returning to normal. He denies headache, jaw tenderness, fever and neck stiffness. He has a past medical history of sleep apnoea, cardiovascular disease and migraines. Examination reveals optic disc swelling and a relative afferent pupillary defect. What is the most likely diagnosis?

Answer 34

Ischaemic optic neuropathy (ION)

Question 35

A 55-year-old woman presents with a sudden onset of painful blurring of vision in her left eye. On examination, the eye appears normal, with normal appearances of the cornea, conjunctiva and pupils. On fundoscopy, she has a left-sided pale and swollen optic disc Given the most likely diagnosis, what is the most appropriate therapy?

Answer 35

High-dose steroids = Typically due to Giant Cell (Temporal) Arteritis

Question 36

A 23-year-old female presents to the emergency department with a 3-day history of eye pain and reduced vision in her left eye On examination, there is a left relative afferent pupillary defect (RAPD), and visual acuity is found to be 6/60 in the left eye What is the definitive investigation for this patient?

Answer 36

MRI Head/Whole Spine with contrast = optic neuritis

Question 37

A 27-year-old man attends A&E. He presented with a 2-day history of the sudden onset of vision loss in his right eye. On moving his right eye, he experiences pain behind his eye. He has a relative afferent pupillary defect in his right eye and a loss of his central visual field. His ability to distinguish between colours, particularly red, is diminished. Fundoscopy reveals a unilateral right-sided papilloedema. Given the likely diagnosis, what is the single best investigation?

Answer 37

MRI head

Question 38

'Right-sided optic neuritis' How do you tell?

Answer 38

(1) Shine light in the right eye = pupils dilate (Relative Afferent Pupillary Defect = RAPD) (2) Swing to the left eye = pupils constrict normally ✅ This means the right optic nerve is affected

Question 39

'Left-sided optic neuritis' How do you tell?

Answer 39

(1) Shine light in the left eye = pupils dilate (2) Swing to the right eye = pupils constrict ✅ This means the left optic nerve is affected

Question 40

'Bilateral optic neuritis' How to tell?

Answer 40

Light in either eye causes reduced constriction or minimal reaction