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Neuro-ophthalmology questions and MCQs for residents

Neuro-ophthalmology covers the afferent and efferent visual systems: the optic nerve, chiasm and retrochiasmal pathways, the pupil, the ocular motor cranial nerves and supranuclear gaze control, and the eyelid and facial nerve disorders that overlap with them. It is the subject of BCSC Section 5 and draws heavily on neuroanatomy, neuroimaging and systemic disease.

Board examiners emphasize localization and the recognition of emergencies: a pupil-involving third nerve palsy, giant cell arteritis, papilledema from raised intracranial pressure and pituitary apoplexy. Expect to match visual field defects to lesion sites, interpret pharmacologic pupil testing, distinguish optic neuritis from ischemic and compressive optic neuropathy, and choose the imaging study that answers the clinical question.

Practice questions work best in this subject when you answer them by localizing first: decide where the lesion is before reading the options, then decide how urgently it must be investigated. Review the decision pathway in each explanation, and use weak-topic drills to return to areas such as nystagmus, supranuclear disorders and pupil pharmacology, where a small anatomical detail often decides the answer.

Free neuro-ophthalmology practice questions

Neuro-ophthalmology questions are in the OphthoMentor app: create a free account to practise them with explanations, flowcharts and spaced-repetition review.

High-yield neuro-ophthalmology topics for boards

  • Relative afferent pupillary defect: swinging flashlight test, causes and pitfalls
  • Horner syndrome: cocaine or apraclonidine to confirm, hydroxyamphetamine to localize
  • Adie tonic pupil: light-near dissociation, dilute pilocarpine supersensitivity
  • Pupil-involving third nerve palsy: posterior communicating artery aneurysm until excluded
  • Fourth nerve palsy: Parks-Bielschowsky three-step test, excyclotorsion, head tilt
  • Sixth nerve palsy as a false localizing sign of raised intracranial pressure
  • Internuclear ophthalmoplegia and one-and-a-half syndrome: MLF and PPRF localization
  • Dorsal midbrain (Parinaud) syndrome: upgaze palsy, convergence-retraction nystagmus, light-near dissociation
  • Optic neuritis: ONTT, brain MRI and MS risk, MOG and aquaporin-4 antibodies
  • Giant cell arteritis: arteritic AION, ESR and CRP, temporal artery biopsy
  • Nonarteritic AION: crowded disc at risk, vasculopathic risk factors
  • Idiopathic intracranial hypertension: Friedman diagnostic criteria, papilledema, sixth nerve palsy
  • Chiasmal syndromes: bitemporal hemianopia, junctional scotoma, pituitary apoplexy
  • Retrochiasmal field defects: congruity, Meyer loop superior quadrantanopia, macular sparing
  • Hereditary optic neuropathies: Leber hereditary optic neuropathy and dominant optic atrophy
  • Optic nerve sheath meningioma: optociliary shunt vessels, tram-track sign
  • Myasthenia gravis: variable ptosis, ice test, antibodies, thymoma evaluation
  • Nystagmus localization: downbeat at craniocervical junction, see-saw with parasellar lesions
  • Cavernous sinus and orbital apex syndromes: combined cranial neuropathies
  • Functional visual loss: nonexpanding tubular fields, optokinetic drum, mirror and prism tests

How neuro-ophthalmology is examined

Neuro-ophthalmology corresponds to BCSC Section 5. On OKAP and the ABO Written Qualifying Examination it typically appears as short clinical vignettes that hinge on localization (a field defect, a pupil finding or a pattern of diplopia) followed by the most likely diagnosis or the next best investigation. Visual field printouts, pupil and motility photographs, optic disc photographs and neuroimaging lend themselves to image-based items.

The EBO Diploma and FRCOphth written papers test the same core: optic neuritis and its differential diagnosis, giant cell arteritis, third nerve palsy, chiasmal compression and idiopathic intracranial hypertension, with the emphasis on safe, time-appropriate investigation and referral.

In oral examinations, neuro-ophthalmology cases are well suited to testing systematic reasoning: describe the finding, localize the lesion, state what must be excluded urgently and outline the workup. Rehearsing that sequence aloud in oral case stations prepares you for the format.