PCO Exam 2: Pupils, EOMs, Cover Test, Visual Fields
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Questions and Answers

What is a correct characteristic of parasympathetic dysfunction of the pupil?

  • Anisocoria more pronounced in dim illumination
  • Anisocoria more pronounced in bright illumination (correct)
  • Ptosis without anisocoria
  • Anisocoria without ptosis in bright illumination

    • What is the term for conditions where the light reflex is absent or abnormal, but the near response is intact?

  • Horner's Syndrome
  • Adie's Tonic Pupil
  • Anisocoria
  • Light-near dissociation (correct)

    • What is the maximum amount of dilation caused by sympathomimetics?

  • 1-2mm (correct)
  • 0.5-1mm
  • 3-4mm
  • 2-3mm

    • Which neuron arc, involved in the parasympathetic pupil constriction to light connects the EW-nucleus to the ciliary ganglion?

    <p>3rd neuron arc</p> Signup and view all the answers

    What is an important point to note about bilateral optic nerve disease?

    <p>RAPD will not be seen , unless the disease is asymmetric</p> Signup and view all the answers

    What artery passes over the preganglionic neurons of the sympathetic innervation to pupil?

    <p>Subclavian artery</p> Signup and view all the answers

    What is the term for the pathway that carries sensory information towards the CNS?

    <p>Afferent pathway</p> Signup and view all the answers

    Which pathway in the midbrain, does the near reflex pass in the EW- nucleus?

    <p>Ventrally</p> Signup and view all the answers

    What type of pathway defects do you rule out when measuring pupil sizes?

    <p>Efferent defects</p> Signup and view all the answers

    What pupil test do you perform if the light responses are abnormal or sluggish?

    <p>Accommodative response</p> Signup and view all the answers

    Will you see a possible APD with a fixed and dilated pupil?

    <p>Yes</p> Signup and view all the answers

    Which part of the brain is the starting point of the 1st neuron in the oculosympathetic pupillary pathway?

    <p>Posterior hypothalamus</p> Signup and view all the answers

    What is the location of the 2nd neuron in the OCULOSYMPATHETIC PUPILLARY PATHWAY?

    <p>Ciliospinal center of Budge</p> Signup and view all the answers

    What level APD is associated with an amaurotic pupil?

    <p>+4 APD</p> Signup and view all the answers

    Which does NOT cause an APD?

    <p>Dense cataract</p> Signup and view all the answers

    What area is affected with anisocoria more pronounced in bright illumination?

    <p>Parasympathetic dysfunction</p> Signup and view all the answers

    What is the effect of time on the accommodative response in Adie's tonic pupil?

    <p>It tends to improve</p> Signup and view all the answers

    What is the concentration of Pilocarpine used in the diagnostic test for Adie's tonic pupil?

    <p>Pilocarpine 0.125%</p> Signup and view all the answers

    What is the effect of Horner's syndrome on the retractor muscles of the eyelids?

    <p>They are weakened</p> Signup and view all the answers

    When is anisocoria more apparent in Horner's syndrome?

    <p>In dark conditions</p> Signup and view all the answers

    What is the term for the slight elevation of the lower lid due to the loss of nerve supply in Horner's Syndrome?

    <p>Upside-down ptosis</p> Signup and view all the answers

    Which type of Horner's Syndrome is NOT associated with anhidrosis?

    <p>Postganglionic lesions</p> Signup and view all the answers

    What is the most common cause of Preganglionic Horner's Syndrome?

    <p>Pancoast tumors</p> Signup and view all the answers

    What is the term for the abnormality of the iris color in congenital Horner's Syndrome?

    <p>Heterochromia</p> Signup and view all the answers

    What type of innervation is responsible for dilating the pupil?

    <p>Sympathetic</p> Signup and view all the answers

    What is the name of the nerve that carries the afferent signal from the retina to the brain?

    <p>Cranial Nerve II</p> Signup and view all the answers

    What is the term for the pathway that connects the retina to the ciliary ganglion and controls pupillary constriction?

    <p>Parasympathetic pathway</p> Signup and view all the answers

    What is the effect of a defect in the afferent pathway on pupillary response?

    <p>Pupillary response will be absent</p> Signup and view all the answers

    What is the name of the muscle responsible for constricting the pupil?

    <p>Sphincter muscle</p> Signup and view all the answers

    Where does the 2nd neuron in the OCULOSYMPATHETIC PUPILLARY PATHWAY terminate?

    <p>Superior cervical ganglion</p> Signup and view all the answers

    What is the effect of interrupting the sympathetic pathway in the OCULOSYMPATHETIC PUPILLARY PATHWAY?

    <p>Horner's Syndrome</p> Signup and view all the answers

    Which part of the brain is the starting point of the 1st neuron in the OCULOSYMPATHETIC PUPILLARY PATHWAY?

    <p>Posterior hypothalamus</p> Signup and view all the answers

    What is the common efferent pathway for pupillary constriction in both the parasympathetic pathway and near reflex?

    <p>EWN to the iris sphincter</p> Signup and view all the answers

    In which type of Horner's Syndrome is anhidrosis NOT present?

    <p>Postganglionic lesions</p> Signup and view all the answers

    What is the term for the recording of pupils that is Equally Round and Reactive to Light and Accommodation, with No Afferent Pupillary Defect in OD and OS?

    <p>PERRLA (-) APD OD/OS</p> Signup and view all the answers

    What is the characteristic of the pupillary light and near responses in Horner's Syndrome?

    <p>Unimpaired pupillary light and near responses</p> Signup and view all the answers

    What is the method used to quantify the Relative Afferent Pupillary Defect?

    <p>NDF (Neutral Density Filter)</p> Signup and view all the answers

    What is the most common cause of isolated CN 3 palsy with pupil involvment?

    <p>Posterior communicating artery aneurysm</p> Signup and view all the answers

    What drop is used to diagnose Adie's Tonic Pupil?

    <p>Pilocarpine 0.125%</p> Signup and view all the answers

    Which optic neuropathy does NOT cause Relative Afferent Pupillary Defect?

    <p>Bilateral optic neuritis</p> Signup and view all the answers

    What is the common accompaniment to congenital Horner's Syndrome?

    <p>Iris depigmentation</p> Signup and view all the answers

    What is the primary mechanism by which cocaine blocks the release of norepinephrine in Horner's Syndrome?

    <p>Blocks the reuptake of norepinephrine from the synaptic cleft</p> Signup and view all the answers

    What is the primary action of apraclonidine on the dilator muscle in Horner's Syndrome?

    <p>Acts on the delayed sensitivity of alpha 1 receptors</p> Signup and view all the answers

    What is the primary application of hydroxyamphetamine in diagnosing Horner's Syndrome?

    <p>Differentiating between preganglionic and postganglionic lesions</p> Signup and view all the answers

    What is the characteristic of the pupil in Horner's Syndrome when apraclonidine is applied?

    <p>Dilation occurs due to hypersensitivity of alpha 1 receptors</p> Signup and view all the answers

    What is the primary mechanism by which apraclonidine produces dilation in the affected pupil in Horner's Syndrome?

    <p>Acts on the delayed sensitivity of alpha 1 receptors in the dilator muscle</p> Signup and view all the answers

    What happens to the retinal image when a prism is placed in front of the eye?

    <p>It is shifted towards the base of the prism</p> Signup and view all the answers

    What is the difference between a tropia and a phoria?

    <p>A tropia is a manifest deviation, while a phoria is a latent deviation</p> Signup and view all the answers

    Which EOM muscle is NOT innervated by the oculomotor nerve?

    <p>Superior oblique</p> Signup and view all the answers

    What is the term for the deviation of the visual axes of the two eyes when stimuli to fusion is operating?

    <p>Tropia</p> Signup and view all the answers

    What is the purpose of the cover test?

    <p>To determine the presence of a latent or manifest deviation</p> Signup and view all the answers

    What is the term for the simultaneous perception of dissimilar objects that project upon corresponding retinal points?

    <p>Visual confusion</p> Signup and view all the answers

    What may cause the sudden onset of strabismus in adults?

    <p>All of the above</p> Signup and view all the answers

    What is the term for the perception of one object that projects upon two different noncorresponding retinal areas?

    <p>Diplopia</p> Signup and view all the answers

    What is the term for a latent deviation of the visual axes of the two eyes, brought on by eliminating all stimuli of fusion?

    <p>Phoria</p> Signup and view all the answers

    What is the purpose of neutralization with prism?

    <p>To measure the magnitude of deviation</p> Signup and view all the answers

    What is the significance of the apex of the prism in neutralization?

    <p>It should be oriented towards the direction of deviation</p> Signup and view all the answers

    What is the purpose of inducing phoria in orthophoria cases?

    <p>To detect a latent phoria</p> Signup and view all the answers

    What is a screening tool to identify strabismus?

    <p>Hirschberg test</p> Signup and view all the answers

    Which muscle is NOT responsible for a head tilt to the right?

    <p>Right inferior rectus</p> Signup and view all the answers

    What type of tropia is characterized by a deviation that occurs only at one testing distance?

    <p>Periodic tropia</p> Signup and view all the answers

    What is the expected finding in exophoria at 6M?

    <p>1Δ XP ± 2Δ at distance</p> Signup and view all the answers

    What is the purpose of the cover test in a strabismus evaluation?

    <p>To evaluate the presence and direction of a tropia</p> Signup and view all the answers

    When recording cover test results, which is correct for a patient with 22 prism diopters of intermittent esotropia at near in the right eye?

    <p>22 PD RE(T)'</p> Signup and view all the answers

    What is the recording abbreviation for a right 20PD constant esotropia at distance?

    <p>20Δ RET</p> Signup and view all the answers

    What is the term for a latent deviation that is brought out by eliminating stimuli to fusion?

    <p>Phoria</p> Signup and view all the answers

    What is the significance of the direction and frequency of deviation in strabismus?

    <p>It indicates the deviated eye and testing distance</p> Signup and view all the answers

    What is the difference between a unilateral cover test and an alternating cover test?

    <p>The unilateral cover test evaluates one eye, while the alternating cover test evaluates both eyes</p> Signup and view all the answers

    What is the term for a deviation that occurs due to the paralysis of a nerve or muscle?

    <p>Paralytic tropia</p> Signup and view all the answers

    What is the purpose of the Hirschberg test in a strabismus evaluation?

    <p>To assess the corneal reflections</p> Signup and view all the answers

    What is the term for a condition characterized by a deviation that is manifest in only one eye?

    <p>Unilateral tropia</p> Signup and view all the answers

    What is the purpose of the Bruckner test in a strabismus evaluation?

    <p>To assess the binocular vision</p> Signup and view all the answers

    What is the term for a deviation that occurs in both eyes, but with different angles of deviation?

    <p>Incomitant tropia</p> Signup and view all the answers

    What Fick's axis runs nasal to temporal?

    <p>X-axis</p> Signup and view all the answers

    What type of prism is used to correct hyper deviation?

    <p>BD prism</p> Signup and view all the answers

    What does a darker reflex indicate in the Bruckner test?

    <p>The fixating eye</p> Signup and view all the answers

    How far, posterior to the cornea, does Fick's axes intersect?

    <p>13.5mm</p> Signup and view all the answers

    What is the primary purpose of Confrontation Visual Fields (CVF) in a patient?

    <p>To screen for potential visual field defects</p> Signup and view all the answers

    What is the correct placement of the overhead lamp in a Confrontation Visual Fields setup?

    <p>Between the examiner and the patient</p> Signup and view all the answers

    What is the examiner's role in a Confrontation Visual Fields test?

    <p>To compare their own visual field to the patient's</p> Signup and view all the answers

    What is the primary function of the peripheral visual field?

    <p>Specialized in the detection of motion signals</p> Signup and view all the answers

    What is the correct way to hold the fingers in a Confrontation Visual Fields test?

    <p>Hold the fingers statically</p> Signup and view all the answers

    What is the purpose of occluding the patient's left eye in a Confrontation Visual Fields test?

    <p>To compare the patient's visual field to the examiner's</p> Signup and view all the answers

    What is the normal range of a single eye's visual field?

    <p>130° to 145°</p> Signup and view all the answers

    What is the location of the physiological blind spot in the visual field?

    <p>15 degrees temporal and 5 degrees inferior from central fixation</p> Signup and view all the answers

    What is the primary reason for including visual field evaluation in all basic optometric exams?

    <p>To quickly and easily screen for visual field defects</p> Signup and view all the answers

    What is the primary use of visual field evaluation in cases of glaucoma?

    <p>For diagnostic decisions and monitoring progression</p> Signup and view all the answers

    What is the primary reason for visual field defects?

    <p>Medications and ocular, systemic, or neurological diseases</p> Signup and view all the answers

    What is the term used to describe a visual field defect that is the same size and shape in both eyes?

    <p>Congruous</p> Signup and view all the answers

    What type of visual field defect is associated with ocular abnormalities?

    <p>Altitudinal</p> Signup and view all the answers

    What is the term used to describe a general reduction in overall sensitivity of the visual field?

    <p>Depression</p> Signup and view all the answers

    What is the term used to describe a loss of ¼ of the visual field in one or both eyes?

    <p>Quadrantanopia</p> Signup and view all the answers

    What is the term used to describe the corresponding visual fields of the two eyes?

    <p>Homonymous</p> Signup and view all the answers

    What is the term used to describe a visual field defect that is above or below the horizontal meridian?

    <p>Altitudinal</p> Signup and view all the answers

    During the testing procedure, what should the examiner remind the patient to do?

    <p>Fixate on the examiner's open eye</p> Signup and view all the answers

    What is the difference between perimetry and campimetry?

    <p>Perimetry measures the visual field using automated targets, while campimetry measures the visual field using manual targets</p> Signup and view all the answers

    What is the purpose of drawing constrictions?

    <p>To record the patient's visual field defects</p> Signup and view all the answers

    What is the difference between a scotoma and hemianopsia?

    <p>A scotoma is a blind spot, while hemianopsia is a loss of half of the visual field</p> Signup and view all the answers

    What type of visual field defect is typically seen in lesions affecting the optic tract or complete optic radiations?

    <p>Homonymous hemianopsia</p> Signup and view all the answers

    What is the characteristic of visual field defects caused by pre-chiasmal altitudinal lesions?

    <p>They respect the horizontal meridian</p> Signup and view all the answers

    What type of lesion can cause a junctional scotoma?

    <p>Lesion to the proximal fibers of the optic nerve</p> Signup and view all the answers

    What is the characteristic of visual field defects caused by glaucoma?

    <p>They cause a generalized depression of the visual field</p> Signup and view all the answers

    What type of lesion can cause an inferior quadrantanopsia?

    <p>Lesion to the parietal lobe</p> Signup and view all the answers

    What is the characteristic of visual field defects caused by retinitis pigmentosa?

    <p>They cause a peripheral visual field defect</p> Signup and view all the answers

    Disjunctive eye movements create vergence.

    <p>True</p> Signup and view all the answers

    Which eye movement is considered a version movement?

    <p>Dextroversion</p> Signup and view all the answers

    Antagonist eye muscles are considered prime movers.

    <p>False</p> Signup and view all the answers

    What is the primary movement of the Superior oblique muscle?

    <p>extorsion</p> Signup and view all the answers

    What is the primary movement of the Superior rectus?

    <p>elevation</p> Signup and view all the answers

    What is the secondary movement of the inferior rectus?

    <p>extorsion</p> Signup and view all the answers

    The secondary movement of the inferior oblique is abduction.

    <p>False</p> Signup and view all the answers

    The oblique muscles are primary muscles for torsion.

    <p>True</p> Signup and view all the answers

    When the eye is fully abducted, the SO and IO are in charge of elevation and depression.

    <p>False</p> Signup and view all the answers

    When the eye is fully adducted, the SO and IO are in charge of elevation and depression.

    <p>True</p> Signup and view all the answers

    Saccades are used to keep the image in the fovea.

    <p>False</p> Signup and view all the answers

    Which EOM muscle is the strongest and largest?

    <p>Medial rectus</p> Signup and view all the answers

    Which is not a sign of isolated CN 4 palsy?

    <p>Binocular horizontal diplopia</p> Signup and view all the answers

    A sign of isolated CN 6 palsy is having one eye not being able to abduct.

    <p>True</p> Signup and view all the answers

    Brown's syndrome is caused by a shortening or tightening of which EOM?

    <p>Superior oblique</p> Signup and view all the answers

    What type of VFD occurs from a lesion of the optic chiasm?

    <p>Bitemporal hemianopia</p> Signup and view all the answers

    A lesion of the parietal lobe will cause a superior quadrantanopsia.

    <p>False</p> Signup and view all the answers

    Where is the location of the lesion to cause a contralateral homonymous superior quadrantanopsia VFD?

    <p>Temporal lobe</p> Signup and view all the answers

    Pre-chiasmal altitudinal defects generally respect the horizontal meridian.

    <p>True</p> Signup and view all the answers

    Most common cause of a right homonymous hemianopsia is due to a stroke of right side of brain.

    <p>False</p> Signup and view all the answers

    Post chiasm defects will have VA loss on the contralateral side of lesion.

    <p>True</p> Signup and view all the answers

    Prechiasm lesions will produce a monocular contralateral defect.

    <p>False</p> Signup and view all the answers

    What type of scotoma is caused by the trial lens being too far from the patient when performing a VF on Humphries?

    <p>Annular scotoma</p> Signup and view all the answers

    Toxicity of drugs used to treat arthritis and lupus can cause a paracentral scotoma.

    <p>False</p> Signup and view all the answers

    Paracentral scotomas are caused by ARMD,exudates, and early glaucomatous VFD.

    <p>True</p> Signup and view all the answers

    Congruous VFD is not the same size and shape in the same eye.

    <p>False</p> Signup and view all the answers

    Study Notes

    Pupil Functions and Anatomy

    • The pupil is an objective indicator of the amount of light transduction by the visual system
    • Pupil size is determined by a balanced tone in the autonomic nervous system (ANS)
    • Afferent and efferent pathways are involved in pupil function:
      • Afferent: carries sensory information towards the CNS
      • Efferent: carries motor impulses from CNS to the muscles
    • Oculosympathetic pupillary pathway:
      • 1st neuron (Central): starts in the posterior hypothalamus and ends in the ciliospinal center of Budge (in C8-T2)
      • 2nd neuron (Preganglionic): leaves the ciliospinal center and travels to the superior cervical ganglion (SCG) at the level of the carotid bifurcation
      • 3rd neuron (Postganglionic): joins the ophthalmic division of the trigeminal nerve (CN V) to reach the ciliary body and the pupil dilator muscle

    Pupillary Abnormalities

    • Horner's Syndrome:
      • Results from interruption of the sympathetic pathway at any level
      • Characterized by ptosis, miosis, and anhidrosis
      • Can be congenital or acquired, and may be caused by trauma, malignancy, or neurological conditions
    • Adie's Tonic Pupil:
      • A benign condition characterized by a dilated pupil that reacts poorly to light
      • More common in females, and often accompanied by hyporeflexia or areflexia
      • Diagnosis is made by instilling pilocarpine 0.125% in the affected eye

    Pupillary Reflexes

    • Light reflex:
      • Afferent pathway: cranial nerve II (optic nerve) perceives light and sends the message to the brain
      • Efferent pathway: cranial nerve III (oculomotor nerve) causes both pupils to constrict
    • Near reflex:
      • Afferent pathway: cranial nerve II (optic nerve) perceives near vision and sends the message to the brain
      • Efferent pathway: cranial nerve III (oculomotor nerve) causes both pupils to constrict and the lens to accommodate

    Pupil Testing

    • Importance of pupil testing: to detect and diagnose pupillary abnormalities
    • Methods of pupil testing:
      • Efferent testing: shine light in one eye and observe the pupil response
      • Afferent testing: shine light in both eyes and observe the pupil response
      • Near and accommodative testing: observe pupil response to near vision and accommodation

    Abnormal Pupillary Findings

    • Anisocoria:
      • Physiological anisocoria: unequal pupil size, but both pupils respond to light
      • Pathological anisocoria: unequal pupil size, and one pupil does not respond to light
    • Pharmacological mydriasis and miosis:
      • Sympathomimetics can cause dilation of the pupil
      • Parasympathomimetics can cause constriction of the pupil### Ocular Motility and Strabismus

    Cover Test

    • Occlude the OD, observe the OS, move occluder to OS, and observe OD
    • Repeat multiple times at a consistent pace to observe movement of both eyes
    • Used to determine the presence or absence of a tropia (unilateral cover test) and phoria (alternating cover test)

    Prisms and Neutralization

    • A prism shifts the retinal image towards the base of the prism
    • Asymmetry in the corneal reflex indicates direction and magnitude of an eye turn
    • Prism is measured in mm (1mm = 22Δ)
    • Different types of prisms:
      • Eso deviation: BO prism
      • Exo deviation: BI prism
      • Hyper deviation: BD prism
      • Hypo deviation: BU prism
    • Neutralization with prism:
      • Orient the prism with the apex in the direction of the deviation
      • Identify the fixating or dominant eye and place the prism over the deviated or non-fixating eye
      • Increase the prism magnitude until no movement is seen, then continue adding prism until a reversal is seen

    Bruckner Test

    • Fixation screening test for strabismus, anisometropia, and media opacities in infants and young children
    • Use an ophthalmoscope at 1m away to observe the red reflexes in both eyes
    • Compare the brightness of the reflexes to determine fixation

    Recording Abbreviations

    • XT: Exotropia
    • ET: Esotropia
    • HT: Hypertropia
    • R: OD (right eye)
    • L: OS (left eye)
    • A: Alternating
    • T: Distance
    • T': Near
    • XP: Exophoria
    • EP: Esophoria
    • ɸ: Orthophoria

    Recording Cover Test Results

    • A tropia/strabismus must be identified by:
      • Direction
      • Frequency
      • Deviated eye
      • Magnitude
      • Testing distance
    • Examples: 20Δ RET, 22Δ RE(T)'
    • Phorias are identified by:
      • Direction
      • Magnitude
      • Testing distance
    • Examples: 8XP/12XP', ɸ/3XP'

    Hirschberg Test

    • Screening tool for strabismus when other precise methods cannot be used
    • Equipment: penlight or transilluminator and occluder
    • Procedure:
      • Instruct the patient to look at the light
      • Occlude the OS and observe the location of the corneal reflex in OD
      • Repeat with OD occluded
      • Remove the occluder and observe the location of the corneal reflex with both eyes open
    • Compare the corneal reflex when one eye is fixating vs when both eyes are fixating

    Confrontation Visual Fields

    • Equipment: occluder and overhead lamp
    • Procedure:
      • Dimly illuminated room
      • Sit facing the patient at eye level at a distance of 60-80cm
      • Without spectacles
      • Occlude the patient's left eye and instruct them to look at your left eye
      • Hold up 1, 2, or 4 fingers in the peripheral visual field
      • Ask the patient to tell you how many fingers you are holding up
      • Repeat in all 8 visual field locations

    Visual Field Defects

    • Terminology:
      • Scotoma
      • Hemianopsia or Hemianopia
      • Quadrantanopsia or Quadrantanopia
      • Altitudinal
      • Homonymous vs. Heteronymous
      • Congruent vs. Incongruent
      • Binasal/Bitemporal
      • Depression or Constriction
    • Visual field defects may be due to:
      • Ocular disease
      • Systemic disease
      • Neurological disease
      • Medications

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    Description

    Test your knowledge of the anatomy and functions of the pupillary pathway, including efferent and afferent testing, near/accommodative testing, and interpretation of results. Learn about pupillary abnormalities, diagnosis, and management.

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