Neuro-ophthalmology Question of the Week: Neuro-ophthalmic Emergencies

Question: Identify 7 symptoms or examination findings that are often associated with pathology that require immediate assessment to enable potential life and/or vision saving emergent therapy?

Correct Answers:
1. Sudden visual loss – arteritic anterior ischemic optic neuropathy, branch or central retinal artery occlusion, ocular ischemia, optic neuropathy, atypical optic neuritis, occipital infarct and mucormycosis, optic nerve compression, pituitary apoplexy, stroke, occipital masses, systemic lupus erythematosus, chronic meningitis, and angle closure glaucoma.
2. Ptosis – myasthenia gravis and Horner syndrome (carotid artery dissection, intracranial malformations, inflammation and masses, and apical lung lesion).
3. Binocular diplopia – cranial nerve paresis (aneurysm, arteritic anterior ischemic optic neuropathy, multiple sclerosis, stroke, tumors), myopathies (myasthenia gravis), and nutritional deficiency (Wernicke encephalopathy).
4. Anisocoria –  partial 3rd cranial nerve paresis (cerebral aneurysm), Horner syndrome (carotid artery dissection, intracranial malformations, inflammation and masses, apical lung lesion) and uncal (transtentorial) herniation.
5. Papilledema – malignant hypertension, intracranial mass lesion, blood dyscrasia, idiopathic intracranial hypertension, inflammation, toxic, autoimmune and, paraneoplastic processes, diabetic papillopathy.
6. Nystagmus –  transient ischemic attack, stroke, intracranial hemorrhage, or tumor (brain-stem and/or cerebello-vestibular pathways from the otoliths, to the cerebellum and entire brainstem up to the thalamus).
7. Head trauma – carotid-cavernous fistulas, traumatic optic neuropathy.

Explanation: The major neuro-ophthalmologic emergencies present with sudden vision loss, ptosis, binocular diplopia, anisocoria, papilledema, nystagmus or trauma. The presence of one or more of these findings should alert us to thoroughly investigate these cases. Failure to recognize the disease process involved and apply appropriate treatment in the early stages is likely to adversely affect the outcome.1,2,3

1. Neuro-ophthalmologic Emergencies. Tourn N, Ing E. AAO Focal Points :XXVI: 9. 2008
2. Neuro-ophthalmological emergencies: which ocular signs or symptoms for which diseases? Cordonnier M, Nechel CV. Acta Neurol Belg 2013:113:215-224
3. How to spot and treat dangerous ptosis. Bilyk JR. Review of Ophthalmology 20012
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