Neuro-ophthalmology Illustrated Chapter 15 – Cavernous Sinus and Orbital Vascular Disorders 1

Questions:
1. What symptoms and signs may develop from an aneurysm of the internal carotid artery within the cavernous sinus?
2. What are the characteristics of direct shunts between the internal carotid artery and the cavernous sinus?
3. What are the characteristics of indirect carotid-cavernous or dural shunts?
4. Does a carotid-cavernous fistula have unilateral or bilateral ocular symptoms?
5. Do carotid-cavernous fistulas always have ocular symptoms?
6. What are 10 ocular findings of a carotid-cavernous fistula?
7. Which of the cranial nerves is most commonly affected by a carotid-cavernous fistula?
8. Can mechanical restriction of extraocular muscles occur with a carotid-cavernous fistula?
9. What diagnosis should be considered in an elderly woman with a mild headache, and elevated intraocular pressure?
10. What should be considered in all patients with a bruit accompanying a chronically red eye?

Neuro-ophthalmology Illustrated Chapter 14 – Orbital Syndromes

Questions:
1. What is an orbital syndrome?
2. What are the common features of the orbital syndromes?
3. What are 5 categories of acute or subacute orbital syndromes?
4. What is the most cause of unilateral or bilateral proptosis?
5. What should be suspected if there is proptosis with globe displacement?
6. What tumor is classically associated with fat atrophy and enophthalmos?
7. Why do patients with an orbital syndrome need to be evaluated urgently?
8. What imaging tests are appropriate for orbital syndromes?
9. Do brain CT and MRI scans often miss orbital processes?
10.Is orbital biopsy often necessary?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 13 – Localization of Findings & Treatment of Diplopia – 3rd and 4th Nerves

Questions:
161. Where do these findings localize the lesion: 4th nerve palsy with contralateral Horner syndrome?
162Where do these findings localize the lesion: 3rd nerve palsy with contralateral ptosis and contralateral superior rectus weakness?
163. Where do these findings localize the lesion: 3rd nerve palsy with contralateral hemiparesis?
164. Where do these findings localize the lesion: 3rd nerve palsy and ipsilateral cerebellar ataxia?
165. Where do these findings localize the lesion: 3rd nerve palsy and contralateral tremor?
166. Where do these findings localize the lesion: 3rd nerve palsy and contralateral ataxia with tremor?
167. Where do these findings localize the lesion: 3rd nerve palsy with vertical gaze palsy, lid retraction, skew deviation, and convergence nystagmus?
168. Where do these findings localize the lesion: 3rd nerve palsy with depressed mental status?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 13 – Localization of Findings & Treatment of Diplopia – 6th nerve

Questions:
156. Where do these findings localize the lesion: Horizontal gaze palsy with ipsilateral facial palsy?
157. Where do these findings localize the lesion: 6th nerve palsy with contralateral hemiparesis?
158. Where do these findings localize the lesion: 6th nerve palsy with ipsilateral 7th nerve palsy and contralateral hemiparesis?
159. Where do these findings localize the lesion: 6th nerve palsy with ipsilateral 7th nerve palsy, deafness, hypoesthesia, Horner syndrome, contralateral pain, thermal hypoesthesia, and ataxia?
160. Where do these findings localize the lesion: 6th nerve palsy with ipsilateral Horner syndrome?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 12 – Skew, Tilt, Whipple & Ocular Neuromyotonia

Questions:
143. What are 7 characteristics of Skew Deviation?
144. What test can help differentiate a 4th nerve palsy from skew deviation?
145. What is the ocular tilt reaction?
146. What transmission pathway is disrupted in skew deviation and the ocular tilt reaction?
147. What infectious condition can cause a vertical gaze palsy?
148. What is the cause of Whipple disease?
149. What are the findings of Whipple disease?
150. Where are saccadic eye movements initiated?
151. Where are smooth pursuit eye movements generated?
152. What is the function of inputs to the visual system from the vestibular nuclear complexes?
153. What is Ocular Neuromyotonia?
154. What are the symptoms of Ocular Neuromyotonia?
155.  What is the usual cause of Ocular Neuromyotonia?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 11 – Vertical Eye Movements

Questions:

135. Where are the critical supranuclear structures mediating vertical gaze located?
136. What are the 4 most important pretectal areas related to vertical eye movement?
137. Where are the burst neurons responsible for vertical saccades located?
138. What serves as the neural integrator for vertical gaze and torsion?
139. For downgaze, where do the axons from the interstitial nucleus of Cajal (INC) project?
140. What are the 4 findings of the Dorsal Midbrain Syndrome?
141. What are 2 other names for the Dorsal Midbrain Syndrome?
142. What is a common cause of the Dorsal Midbrain Syndrome?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 10 – Convergence, Divergence & Ocular Motor Apraxia

Questions:
125. What is congenital ocular motor apraxia?
126. What is convergence spasm?
127. What is the cause of convergence spasm?
128. What test will usually differentiate convergence spasm from a bilateral 6th nerve palsy?
129. What is convergence insufficiency?
130. How is convergence insufficiency treated?
131. What are causes of convergence insufficiency?
132. What is divergence insufficiency?
133. What causes divergence insufficiency?
134. What lesion location is likely in the presence of horizontal conjugate deviation of the eyes to one side?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 7 – Lesion Involves Multiple Cranial Nerves

Questions:
92. What signs when associated with lesions causing unilateral or bilateral ophthalmoplegia may help localize the lesion?
93. What are the findings of the orbital apex syndrome?
94. Do brainstem lesions often produce multiple cranial nerve palsies?
95. What are 4 systemic disorders that affect the cranial nerves?
96. What condition should be considered in patients with unilateral or bilateral ophthalmoplegia and normal pupils presumed to result from multiple cranial neuropathies?
97. What is the likely cause of a painful orbital apex syndrome in a diabetic patient?
98. Do normal orbital imaging studies rule out an orbital apex lesion?
99. Does the orbital apex syndrome involve the second division of the fifth nerve?
100. What are the findings of the cavernous sinus syndrome?
101. If a cavernous sinus syndrome includes venous hypertension (carotid-cavernous fistula or cavernous sinus thrombosis), what additional findings may be present?
102. Which cranial nerves are enclosed in the lateral wall of the cavernous sinus?
103. Why do cavernous carotid artery aneurysms often present with an isolated sixth nerve palsy?

Neuro-ophthalmology Illustrated Chapter 13 Diplopia 6 – 3rd Nerve Palsy

Questions:
71. How are 3rd nerve dysfunctions classified?
72. What is the definition of a partial 3rd nerve palsy?
73. What are the two categories of complete 3rd nerve palsies?
74. What is meant by “a pupil-sparing 3rd nerve palsy”?
75. What tests should be done when a patient over age 50 presents with an isolated incomplete 3rd nerve palsy and the pupil is involved?
76. What should be done when a patient over age 50 presents with an isolated complete 3rd nerve palsy and the pupil is Not involved?
77. What should be done when a patient over age 50 presents with an isolated complete 3rd nerve palsy, the pupil is Not involved; normal blood glucose, CBC, platelets, ESR, and CRP is followed daily and develops pupillary involvement?
78. What is the most common cause of an isolated “pupil-sparing 3rd nerve palsy”?
79. Are microvascular 3rd nerve palsies painful?
80. What should be ruled-out when making the diagnosis of a microvascular complete 3rd nerve palsy with pupil-sparing in a patient over 50?
81. What in addition to cranial arteritis should be considered when making the diagnosis of a microvascular pupil complete 3rd nerve palsy with pupil-sparing?
82. How long does it usually take for a microvascular 3rd nerve palsy to resolve?
83. If a complete 3rd nerve palsy with pupil-sparing thought to be of microvascular origin does not clear in 4 months what should be done?
84. What test should be done in a patient under age 50 who presents with an isolated 3rd nerve palsy with or without pupillary involvement?
85. Should the pupils of a patient with an acute 3rd nerve palsy with “pupil sparing” be dilated to complete the eye exam?
86. A patient without a history of trauma has signs of aberrant regeneration of the 3rd nerve. What should be ruled-out?
87. What are the symptoms of pituitary apoplexy?
88. What are the findings when there is a unilateral lesion of the entire 3rd nerve nucleus?
89. Why does a complete unilateral nuclear 3rd nerve palsy have bilateral ptosis?
90. Why does a complete unilateral nuclear 3rd nerve palsy have bilateral elevation deficits?
91. What are the findings of a unilateral lesion of the 3rd nerve fascicle?

Neuro-ophthalmology Illustrated Chapter 13 – Diplopia 5 – 4th Nerve Palsy

Questions:
61. What are 6 characteristics of a 4th nerve palsy?
62. When a patient has a 3rd nerve palsy and the eye cannot adduct, how can the function of the ipsilateral 4th nerve shown to be present?
63. What 5 other conditions should be considered when the patient has the findings of a 4th nerve palsy?
64. A patient has a 4th nerve lesion associated with a contralateral Horner syndrome, where does this localize the lesion?
65. A microvascular 4th nerve palsy is suspected because the 60-year-old patient has diabetes, hypertension, and hyperlipidemia what tests should be ordered?
66. A presumed microvascular 4th nerve palsy in a 60-year-old patient with diabetes, hypertension, and hyperlipidemia has not resolved within 3-6 months, what tests should be ordered?
67. A 40-year-old patient appears to have a 4th nerve functional defect. What diagnoses in addition to 4th nerve palsy should be considered?
68. A 60-year-old patient presents with intermittent vertical diplopia with the findings of a 4th nerve palsy on the 3-step-test. What in addition to an acquired 4th nerve palsy, restriction, myasthenia, Wernicke encephalopathy, and cranial arteritis should be considered? 
69. Are congenital fourth cranial nerve palsies common?
70. What are 3 findings characteristic of a congenital a decompensated congenital 4th nerve palsy?