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Peds neuro boards, V2 > Ophthalmology / Otology > Flashcards

Ophthalmology / Otology Flashcards

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1
Q

Most common genetic cause for congenital visual impairment (1) and other features (3)

A
  1. Leber convenital amaurosis (retinal dystrophy)
  2. Features
    1. Visual impairment beginning a 3-4 months > nystagmus and sluggish pupils
    2. midface hypoplasia
    3. Cognitive / developmental delay
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2
Q

What does this show?

A 
Optic nerve edema from optic neuritis
NOT papilledema (pictured below)
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3
Q

What does this show?

A

Optic disk edema and splinter hemorrhages 2/2 AION

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4
Q

What does this show?

A

Optic atrophy (From longstanding MS)

  • pale, “shrunken” appearing disc
  • pallor extends beyond margins of disc
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5
Q

Location of vertical and horizontal Gaze Centers

A
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6
Q

Centers for:
Saccaddes
Pursuit

A
  1. Saccades
    1. Contralateral frontal lobe
  2. Pursuit
    1. Ipsilateral parietal / occipital
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7
Q

nerve most commonly injured in head trauma

A

CN IV

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8
Q

Midbrain:
Structures (7)
Locations of Injury (2)

A
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9
Q

Lesions of the third Nerve Nuclei

A
        1. Superior rectus nucleus (Contralateral)
  2. Levator nucleus (levator palpebrae)
    1. NOTE: single nuclei controls both eyes
      6.
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10
Q

Patient arrives with right CN III nuclear palsy:

how do you tell if the levator nuclei was damaged?

A
  1. levator nuclei
    1. Bilateral ptosis (injured) or NO ptosis at all (not injured)
  2. Superior rectus nuclei
    1. Injured = left SR is damaged
    2. not injured: NO SR damage
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11
Q

Patient arrives with right CN III palsy and bilateral ptosis

what was damaged?

A

CN III nuclei with invovlement of levator palpebare nucleus

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12
Q

Pons Anatomy (9)

A
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13
Q

Patient arrives with isolated CN III palsy
What is the significance of also having:

Contralateral hemiparesis? (3)
Contralateral hand tremor? (3)
Cerebellar ataxia? (3)
Contralateral hand tremor AND cerebellar ataxia?

A
  1. Contralateral hemiparesis = Weber
    1. CN III fascicle
    2. pyramidal tract
  2. Contralateral hand tremor = benedikt syndrome
    1. CN III fascicle
    2. Red nucleus
  3. Cerebellar ataxia = Nothnagles
    1. CN III fascicle
    2. superior cerebellar peduncle
  4. Both 2 and 3 = claude’s syndrome
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14
Q

Patient arrives with Abducens palsy
what is the significance of also having:

Ipsilateral Facial palsy + Contralateral Hemiparesis (4).

Ipsilateral loss of facial sensation, facial palsy, and horners syndrome?

A
  1. VI, VII palsy + CL hemiparesis = Millard-Gubler syndrome
    1. VI fascicles
    2. VII fascicles
    3. Pyramidal tract
  2. Facial sensation, facial palsy, and horners = Fovile’s syndrome
    1. CN V
    2. CN VI nucleus
    3. CN VII nucleus and sympathetics
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15
Q

Why does blown pupil with CN III raise concerns?

A

Nerve fibers corresponding to pupillary constriction are in the periphery, and thus are targeted during compressing lesions (like aneurysm)

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16
Q

Features of Dorsal Midbrain syndrome

A

Vertical gaze palsy

Convergence - retraction nystagmus

lid retraction

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17
Q

Patient comes in with:
Vertical gaze Palsy
lid Retraction
Pulsating in-and-out movements of eyes with vertically moving OKN drum

Where is the lesion?
what are you suspecting as the cause?
what would you not expect to see?

A

Dorsal midbrain (Dorsal midbrain syndrome)

suspect:
OLD = Stroke
young = Pinealoma

would NOT expect to see pupillary light-near dissociation

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18
Q

Patient unable to look left, but eyes look left when head is passively turned to the right

what does this tell you?

A

This is a supranuclear lesion due to positive doll’s eye maneuver

(possibly due to frontal lobe stroke)

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19
Q

Horizontal or vertical gaze palsy but positive Doll’s eye in that direction suggets what?

A

supranuclear lesion

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20
Q

What does this show?

what is damaged?

What two other features will you see?

A

Bilateral Intranuclear ophthalmoplegia (bilateral limitation of ADDuction)

Damage to medial longitudinal fasciculus

Will also see:
beating nystagmus of adducting eye
vertical skew deviation = vertical diplopia

(#2)

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21
Q

What does this show?

what is the syndrome?

A

Right horizontal Gaze palsy + Right medial rectus palsy when looking left

One-and-a-half-syndrome

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22
Q

“Painful horners”

Make sure to rule out what?

What should you also see (3)?

A

Carotid Dissection

Vision loss IL to horners
Headache IL to horners
CL hemiparesis

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23
Q

What is damaged here?

What will worsen the pupillary finding?

A

Sypathetic innervation to the right eye (horners)

Anisocoria will be more evident in DIM light (sympathetics / Dilation is what is affected)

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24
Q

How would we confirm this diagnosis?

Option 1:
what drug?
what do you see?

Option 2:
what drug?
what do you see?

A

Option 1: Cocaine

  1. Affected Pupil will NOT dilate

Aproclonidine

  1. Affected WILL dilate
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25
Threshold for physiologic anisocoria
\<1-2 mm
26
What is this showing? What does this suggest? If this _wasn't_ present, what would you want to exclude?
Horners syndrome with hypochromia of the iris **congenital** horners (also feed into melanocytes of eye) pediatric acquired horners = r/o **pineoblastoma**
27
Woman with this eye finding and "wiggly" pupillary movements. What other finding would you see? How would you test?
Light-near dissociation (picture) _Dilute_ Pilocarpine Will cause constriction (because it's hypersensitive)
28
Woman with this eye finding and "wiggly" pupillary movements. what is injured? what are the two most common causes?
Ciliary gangion "wiggly" = **vermiform movements** most common causes: post-viral trauma / surgery to eye
29
What does this show? What conditions can you see it in (3) ?
Light-Near dissociation Seen in: Argyll-Robertson pupil (tertiary syphilis) Parinaud's dorsal midbrain syndrome (stroke in adult, pinealoma in children) Adie's tonic pupil (post-viral or post-surgery) | (accomodates but does not react)
30
Label the Following:
31
Diseases associated with Unilateral central scotoma _Bilateral_ central scotoma
Unilateral central scotoma = optic neuritis / MS Bilateral = toxic / medication * Ethambutol for tuberculosis * Thiamine deficiency * Leber's hereditary neuropathy
32
leber's hereditary neuropathy: Vision problems are worse with \_\_\_\_\_
Smoking
33
Difference between pituitary *micro*adenoma and pituitary *macroadenoma* and why is it imporant?
``` Microadenoma = \<10 mm macroadenoma = \>10 mm ``` \> 10 mm and you are more likely to have visual impairment
34
Patient reports loss of vision only when sketching fine details in sketchbook what tumor could cause this? what is it typically associated with?
Tumor in optic chiasm (i.e. Pineal tumor) typically associated with bitemporal hemianopsia when convergin, "blind" temporal fields overlap
35
What should this make you worry about?
Central lesion (bow-tie atrophy)
36
What is this showing? what causes this finding?
Junctional scotoma central scotoma in one eye + suprerotemporal defect in other eye Lesion to anterior part of chiasm infranasal fibers move up to opposite optic nerve before decussating (Von Wilbran's knee)
37
What is this showing? what is it suggestive of? what should NOT be affected?
Homonimous field defect with weird wedge damage to lateral geniculate nucleus lesion pupillary light reflex should NOT be affected
38
What is this showing? What does this suggest?
"pie in the sky" defect right temporal lobe defect
39
What oculomotor finding are suggestive of parietal lobe lesion?
Defects in OKN drum | (persuit / saccade)
40
Label the following and the associated Visual fields
41
Match the following with the visual field defect
42
What is this? features (2) Vision? What is it seen in (3) Epidemiology note
Morning glory Disk Funnel-shaped staphyloma radial vessels Poor vision (hand motion) Seen in: serous retinal detachment basal encephalocele signifies vascular development failure
43
What causes this?
Incomplete closure of embryonic fissure Also associated with visual field defects relative Afferent pupillary defect RAPD
44
What non-neurologic evaluation should this person get?
(optic nerve hypoplasia) Endocrine evaluation (due to midline defects)
45
Conditions associated with this finding
(optic nerve hypoplasia) Associated with: midline hemispheric defects maternal DM, drug, EtOH
46
Retina Versus Visual field Nasal retina Temporal retina
Nasal retina = Temporal visual field Temporal retina = nasal visual field
47
What tests could you order to confirm this finding?
calcified nodules (drusen) CT
48
What can cause this?
Bilateral lateral compression of chiasm such as calcivfied internal carotid arteries
49
Function of inferior oblique inferior rectus
Inferior oblique: Elevates and Extorts inferior rectus: depresses and extorts ## Footnote **"inferiors extort"**
50
what structure is responsible for circadian rhythms?
Suprachiasmic nucleus (hypothalamus)
51
Terms: internal ophthalmoplegia VS external ophthalmoplegia
Internal ophthalmoplegia: loss of parasympathetic innervation to sphincter papillae (results in miadriasis) External ophthalmoplegia = paralysis of external ocular muscles
52
Cranial nerve Palsies which spare the pupil (3)
"**_I_**nside the ***I***, it is **_DiM_** * *_I**_ncomplete _**I_**schemic lesions * *_D_**iabetes, **_M_**yasthenia
53
Ciliary nerves responsible for: pupil Dilation pupil constriction
Pupil dilation: Long ciliary nerve Pupillary constriction: Short ciliary nerve
54
Emboli to the Eye and what they signify: Small, shiny emboli to the eye lodged in retinal arteriole Gray, globular emboli completely occluding retina Long, gray emboli
1. Hollenhorst plaque: 1. signififies prior ischemic damage to eye (treating upstream vessel may prevent further embolization injury) 2. Calcific emboli: disease heart valves 3. Platelit-fibrin emboli: **endogenous**
55
Baby comes in with Infantile spasms and Agenesis of the corpus callosum Why is this in the "ophthalmology" slide deck?
**Aicardi syndrome** can have chorioretinal Lacunae, look for it. AICardi Ageneis of corpus callosum Infantile spasms Chorioretinal Lacunae
56
Lens Deviation: _upwards_ deviation, think \_\_\_\_\_ _downwards_, think \_\_\_\_
Upwards = marfans Downwards = Homocystinuria
57
Dancing eyes, dancing feet What do you look for in child (2) what do you look for in adult (4)
Child 1. Urine catecholimines due to neuroblastoma Adult 1. Anti-Ri due to cancer of (_anti-R_epublican **_BL_**o_G_) 1. Breast 2. Lung 3. Gynecologic
58
Slow vertical saccades + square-wave jerks suggest what?
Progressive supranuclear palsy
59
Woman with MS-like lesions but bilateral retinal artery occlusions: What do you think about? what are it's features?
Susac's syndrome Bilateral retinal artery occlusions Encephalopathy sensorineural hearing loss
60
Mnemonic for Whipple's disease
_My_ _Super_ **_D_**uodenum **_S_**mells **_L_**ike **_W_**e **_C_**an't **_D_**igest **_N_**othing Classic triad: * **_My_**oclonus * **_supra_**nuclear palsy * **_d_**ementia Other features * **_S_**teatorrhea * **_L_**ymphadenopathy * **_W_**eight loss * **_C_**onvergence/**_D_**ivergence **_N_**ystagmus (pendular nystagmus with simultaneous jaw movements; **whipple's eyes**) Caused by trophermya whippelii (PAS +)
61
Hallucination roundup: 1. Formed hallucinations 2. unformed visual hallucinations 3. real objects look malformed, smaller, or larger 4. Hypnogogic / hypnopompic 5. pendular hallucinations
1. Formed hallucinations = Temporal lobe epilepsy 2. unformed visual hallucinations = occipital lobe epilepsy 3. Malformed (metamorphosia), smaller (micropsia), larger (macropsia) = migraine 4. Hypnogogic / hypnopompic = narcolepsy 5. Pendular = midbrain injury
62
Thalalamic nuclei for vision and hearing
L = Light (lateral geniculate nucleus) M = Music (Medial geniculate nucleus)
63
Dix Hallpike Maneuver: How do you do it? What constitutes a "positive" test?
How to do it: * Start in reclining position with head back roughly 20 degrees * Tilt head 45 degrees and bring patient up from reclining to sitting position Positive result: * Upward nystagmus when patient is reclining * downward nystagmus when sitting up
64
45- year old man complains of Vertigo, tinnitus and "fullness" in ears What does he have? what else would you expect (2)? What 3 things should he avoid?
_Menier's disease u_ * Features * Vertigo with "fullness" in ears * Tinnitus * _Low-frequency hearing loss (compared to high frequency associated with loud sound exposure)_ * _+/- horizontal nystagmus_ * Risk factors * Excessive salt intake * head trauma * Cigarette / EtoH use
65
Infant presents with sensorineural hearing loss: 1. Name 4 congential infections that could cause this 2. If also has retinitis pigmentosa, what could this be? 3. If no RP but instead Goiter is present, what could this be?
1. Congential infections causing sensorineural hearing loss 1. Toxoplasmosis 2. CMV 3. Rubella 4. HSV 2. Sensorineural hearing loss + RP suggests **usher syndrome** 3. Sensorineural hearing loss + goiter suggest **Pendred syndrome**.
66
Older man comes in with unsteady gait, incontinence, dementia, and tinnitus. What does the tinnitus sound like?
Venous Hum (pulsatile tinnitus with NPH)
67
What common prophylactic drug can result in subjective tinnitus
Aspirin
68
Differe AION versus NAION
AION = more likely to have superior altitudinal defects (also seen with glaucoma) NAION more likely to have inferior
69
Label the following and important elements of each
1. Red = cochlear promontory 1. site of glomus tympanic paragangliomas 2. Purple = tympanic segment of facial nerve 3. Blue = Tegmen tympani 1. separates cranial and tympanic caveties 4. Orange = Malleus 1. one of the ossicles of middle ear 5. Yellow = Scutum 1. first bony structure to be eroded by enlarging cholesteatoma
70
Patient presents with peripheral vertigo How should their eyes move?
Horizontal / rotary nystagmus directed with fast phase _away_ from affected size
71
"horners but with intact sweating" What study should he get?
MRA to check for carotid dissection | ("post-ganglionic horners")
72
Child is unable to hear soft voices in quiet background, but can hear loud voices in a noisy background? What does this suggest?
Conductive hearing loss | (opposite would be sensorineural)
73
Patient with Vertigo only during severe storms and conductive hearing loss What is this called? What does he have? How would you confirm diagnosis?
Superior semicircular canal dehiscence syndrome Tullio's phenomenon (sound-induced vertigo) Confirm with Hennebert sign (pressure-induced vertigo)
74
How would you treat this patient?
Iodine / steroids / immunosuppression / referral to endocrinology (Graves disease, note sparing of lateral rectus, this is characteristic of Graves)
75
Patient pesents with Pigmentary retinopathy. What medications would you worry about if patient has: Autoimmune conditions (2) schizophrenia (2) HIV (1) Cancer (2)
* Autoimmune conditions * Chloroquine * Hydroxychloroquine * Schizophrenia * Thioridazine * chlorpromazine * HIV * Ritonavir * Cancer * Cisplatin * BCNU
76
Best test to localize Horners syndrome and findings
Hydroxyamphetamine Dilates normally after administration: 1st or 2nd order motor neuron disease
77
Patient presents with bilateral fluctuating hearing loss, episodic vertigo, and interstitital keratitis. How do you treat?
Cogan's syndrome Treat with high dose steroids followed by immunosuppression if unresolved
78
Patient presents with gaze-evoked and vestibular nystagmus What is this called? What can this indicate?
Bruns nystagmus Larege cerebellopontine angle tumor (such as vestibular schwannoma)
79
Factors associated with poorer prognosis in PRES
Corpos callosum involvent
80
Define Saccadomania (2)
1. Flutter - random horizonal eye movements (MS) 2. Opsoclonus": random, chaotic, multiplanar eye movements
81
Brain regions and associated wye movements Saccades : smooth pursuit: Additional note for optokinetic drumq
Saccades: contralateral frontal lobe pursuit: IL pareito/occipital lobe (ill-defined) Note on optokinetic drum: Allows you to assess one side of brain for each (smooth pursuit followed by saccade in other direction)
82
Patient presents with opsoclonus. What do you think of it patient is... A child An adult
Child: neuroblastoma Adult: paraneoplastic
83
What regions are responsible for: Saccades Pursuit
Saccades (FAST): **contralateral** frontal lobe Pursuit (slow): **ipsilateral** parietooccipital region (ill-defined)
84
Patient presents with optokinetic nystagmus. what has been damaged? parietal lobe lesion ipsilateral to where smooth persuit is lost.
85
Reaction of eye drops in horners Aproclonidine Cocaine 1% hydroxyamphetamine
1. Aproclonidine 1. _affected_ pupil dilates, _affected_ lid elevates 2. Cocaine 1. _unaffected_ eye will dilate 3. Hydroxyamphetamine 1. dilation if _affected_ eye **if 1st or 2nd order neuron**

Peds neuro boards, V2 (29 decks)

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