Questions:
10. What should 2 conditions should be suspected in a patient with binocular diplopia, marked esotropia, and an apparent bilateral gaze palsy?
11. What are the findings of convergence spasm?
12. In a patient with binocular horizontal diplopia, marked esotropia, and an apparent bilateral gaze palsy what exam 4 techniques can be used to rule-out convergence spasm?
13. What are 3 characteristics of voluntary nystagmus?
14. What is the visual complaint of patients with voluntary nystagmus?
15. What pharmacologic agents should be used to rule-out pharmacologic mydriasis in a patient with a fixed dilated pupil?
16. Will mydriasis from a 3rd nerve palsy constrict to 0.1% pilocarpine?
17. If a pupil constricts with 0.1% pilocarpine what condition is present?
18. Will mydriasis from a 3rd nerve palsy constrict to 1% pilocarpine?
19. Will a pupil with pharmacologic mydriasis fully constrict to 1% pilocarpine?
20. A patient with best corrected distance visual acuity of 20/20, is unable to read better than J10 at near. What test can determine if the cause is inorganic?
21. How can nonorganic unilateral ptosis be differentiated from organic ptosis?
22. How can nonorganic blepharospasm be treated?
23. After it has been established that the patient’s symptoms are functional, what approach to treatment should be taken?

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Questions with answers:
10. What should 2 conditions should be suspected in a patient with binocular diplopia, marked esotropia, and an apparent bilateral gaze palsy?
Bilateral 6th nerve palsy & Convergence spasm 

11. What are the findings of convergence spasm?
The findings of convergence spasm include episodes of intermittent, convergence, accommodation, and miosis. 

12. In a patient with binocular horizontal diplopia, marked esotropia, and an apparent bilateral gaze palsy what exam 4 techniques can be used to rule-out convergence spasm?
1. Test the vestibulo-ocular reflex with the doll’s eye maneuver.
2. Perform horizontal ductions. In convergence spasm, ductions are normal which rules-out 6th nerve palsies, and the miosis resolves.
3. Patching one eye and observing for an extended period of time. 
4. Cycloplegic eye drops.

13. What are 3 characteristics of voluntary nystagmus?
1. It can be sustained for only 10-12 seconds.
2. It is often associated with the simultaneous fluttering of the eyelids. 
3. Convergence is present. 

14. What is the visual complaint of patients with voluntary nystagmus?
Patients complain of oscillopsia and reduced vision.

15. What pharmacologic agents should be used to rule-out pharmacologic mydriasis in a patient with a fixed dilated pupil?
When evaluating a patient with suspected pharmacologic mydriasis, dilute pilocarpine (0.1%) should be used first to rule-out Adie pupil. If there is no pupillary constriction has occurred after 45 minutes, then 1 or 2% pilocarpine should be administered. A failure to dilate with 1 or 2% indicates pharmacologic mydriasis.

16. Will mydriasis from a 3rd nerve palsy constrict to 0.1% pilocarpine?
No, mydriasis from a third nerve palsy will not fully constrict with pilocarpine 0.1%

17. If a pupil constricts with 0.1% pilocarpine what condition is present?
Adie pupil

18. Will mydriasis from a 3rd nerve palsy constrict to 1% pilocarpine?
Yes, mydriasis from a third nerve palsy will fully constrict with pilocarpine 1%.

19. Will a pupil with pharmacologic mydriasis fully constrict to 1% pilocarpine?
No, the pupil with pharmacologic mydriasis will not fully constrict to 1% pilocarpine.

20. A patient with best corrected distance visual acuity of 20/20, is unable to read better than J10 at near. What test can determine if the cause is nonorganic?
Patients with nonorganic weakness or paralysis of accommodation are usually unable to read at near, even with a plus lens. Some patients improve only partially with a corrective plus lens. All patients with organic accommodation paralysis should be able to read at near with the appropriate plus lens correction. 

21. How can nonorganic unilateral ptosis be differentiated from organic ptosis?
Patients with nonorganic ptosis voluntarily close the eye and lower the ipsilateral brow unlike patients with organic ptosis who will elevate the ipsilateral brow. 

22. How can nonorganic blepharospasm be treated?
Although blepharospasm is most often organic and involuntary, repeated eyelid closure may be nonorganic. In both cases, treatment with botulinum toxin is highly effective. 

23. After it has been established that the patient’s symptoms are functional, what approach to treatment should be taken?
Because nonorganic visual symptoms and signs often result from anxiety and depression, reassurance that there is no underlying lesion and that visual symptoms should spontaneously resolve often results in improvement. Once normal visual function is proven, there is no need to pursue further testing. Follow-up should be done to be certain that is no organic disease develops. 

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The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Biousse V and Newman NJ. 2012. Thieme

18.2.4 When the Complaint Is Binocular Diplopia
In these cases, spasm of the near triad is very common and is characterized by episodes of intermittent convergence, accommodation, and miosis (▶Fig. 18.9). When ductions are tested with one eye covered, eye movements are normal, and the miosis resolves.

18.2.5 When the Complaint Is Nystagmus
Voluntary nystagmus is characterized by rapid movements of the eyes that are purposely initiated. These rapid alternating saccades can usually be sustained for only a few seconds. Fluttering of eyelids during episodes, often with convergence, can be seen.

18.2.6 When the Complaint Is Pupillary Dilation
Pharmacologic pupillary dilation results in widely dilated pupils. It can be unilateral or bilateral. The dilated pupil does not constrict in response to light or near stimulation. There is no constriction with dilute pilocarpine 0.1% (unlike tonic pupil), and there is no or incomplete constriction with pilocarpine 1% (▶Fig. 18.10).

When evaluating a patient with suspected pharmacologic mydriasis, dilute pilocarpine should be used first. If there is no pupillary constriction after 45 minutes, then 1%pilocarpine can be used.

Pearls
Mydriasis from a third nerve palsy will fully constrict with pilocarpine 1%.

18.2.7 When the Complaint Is Accommodation Paralysis
Patients with nonorganic weakness or paralysis of accommodation are unable to read at near, even with a plus lens. Some patients improve only partially with a corrective plus lens (all patients with organic accommodation paralysis should be able to read at near with the appropriate plus lens correction).

18.2.8 When the Complaint Is Ptosis
Nonorganic unilateral or bilateral ptosis is rare. These patients voluntarily close the eye and lower the ipsilateral brow (unlike patients with true ptosis, who elevate the ipsilateral brow) (▶Fig. 18.11 and ▶Fig. 18.12).



18.2.9 When the Complaint Is Blepharospasm
Although blepharospasm is most often organic and involuntary, repeated eyelid closure may be nonorganic. In both cases, treatment with botulinum toxin may be highly effective.

Pearls
Because nonorganic visual symptoms and signs often result from anxiety and depression, reassurance that there is no underlying lesion and that visual symptoms should spontaneously resolve often results in improvement. Once normal visual function is proven, there is no need to pursue further testing.

Reference: 1. Neuro-ophthalmology Illustrated-2nd Edition. Biousse V and Newman NJ. 2012. Thieme

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