Both nuclear/infranuclear and supranuclear ocular pathways ultimately involve brainstem nuclei of:

A. II, III, and IV
B. III, IV, and VI
C. III, V, and VII
D. IV, V, and VI

B. III, IV, and VI

The lateral, superior, medial, and inferior rectus muscles insert onto the:

A. Cornea
B. Lens capsule
C. Tarsal plate
D. Sclera

D. Sclera

Which of the following best describes the anatomical path (origin, pulley, and insertion) of the superior oblique muscle?

A. Originates from the body of the sphenoid, passes through the trochlea, and inserts on the superior-lateral globe.

B. Originates from the body of the sphenoid, passes through the annulus of Zinn, and inserts on the inferior globe.

C. Originates from the medial orbital wall, passes through the trochlea, and inserts on the superior globe.

D. Originates from the maxilla, passes through the annulus of Zinn, and inserts on the lateral globe.

A. Originates from the body of the sphenoid, passes through the trochlea, and inserts on the superior-lateral globe.

Intorsion is:

A. Downward movement of the eye
B. Nasal deviation of the globe
C. Upper pole moves inward
D. Upper pole moves outward

C. Upper pole moves inward

Extorsion is:

A. Medial rotation of lower pole
B. Upper pole moves outward
C. Lateral translation of globe
D. Downward movement in abduction

B. Upper pole moves outward

Which of the following best describes the anatomical origin and insertion of the inferior oblique muscle?

A. Originates from the anterior medial orbital floor (maxilla) and inserts on the inferolateral globe.

B. Originates from the orbital apex (annulus of Zinn) and inserts on the inferior sclera.

C. Originates from the sphenoid bone, passes through the trochlea, and inserts inferiorly.

D. Originates from the common tendinous ring and inserts on the superior globe.

A. Originates from the anterior medial orbital floor (maxilla) and inserts on the inferolateral globe.

Abduction (lateral) movement of eye

Lateral rectus

Adduction (medial) movement of eye

Medial rectus

Elevation and intorsion

Superior rectus

Depression and extorsion

Inferior rectus

Elevation and extorsion

Inferior oblique

Depression and intorsion

Superior oblique

Levator palpebrae superioris primarily:

A. Elevates the eyelid
B. Constricts the pupil
C. Abducts the eye
D. Accommodates the lens

A. Elevates the eyelid

The ciliary muscle primarily:

A. Abducts the globe
B. Elevates the eyelid
C. Adjusts lens thickness
D. Constricts the palpebral fissure

C. Adjusts lens thickness

CN III, IV, and VI pass through the _____ and enter the orbit via the _____.

A. Optic canal; orbital apex
B. Jugular foramen; optic canal
C. Foramen rotundum; fissure
D. Cavernous sinus; superior orbital fissure

D. Cavernous sinus; superior orbital fissure

The superior division of the oculomotor nerve innervates the:

A. Medial rectus and inferior rectus
B. Levator and superior rectus
C. Inferior oblique and levator
D. Superior rectus and medial rectus

B. Levator and superior rectus

The inferior division of the oculomotor nerve supplies the:

A. Medial rectus, inferior rectus, inferior oblique
B. Superior rectus, inferior rectus, inferior oblique
C. Lateral rectus and inferior rectus
D. Superior oblique and medial rectus

A. Medial rectus, inferior rectus, inferior oblique

The inferior division of CN III carries which fibers to which targets?

A. Motor fibers to lateral rectus
B. Sensory fibers to cornea
C. Preganglionic parasympathetics to pupil and ciliary muscle
D. Postganglionic sympathetics to iris dilator

C. Preganglionic parasympathetics to pupil and ciliary muscle

The Edinger-Westphal nucleus contains:

A. Branchial motor neurons
B. Preganglionic parasympathetic neurons
C. General sensory neurons
D. Somatic sensory neurons

B. Preganglionic parasympathetic neurons

Parasympathetic fibers from the Edinger–Westphal nucleus are especially vulnerable to aneurysms of the:

A. Posterior communicating artery
B. Anterior cerebral artery
C. Superior cerebellar artery
D. Middle cerebral artery

A. Posterior communicating artery

A painful oculomotor palsy with pupillary involvement should raise greatest concern for:

A. Cavernous sinus thrombosis
B. Diabetic neuropathy
C. Posterior communicating aneurysm
D. Myasthenia gravis

C. Posterior communicating aneurysm

Can unilateral weakness of levator palpebrae superioris and pupillary dilator muscles be caused by a single unilateral lesion?

A. Yes, usually
B. Yes, always
C. Sometimes
D. No

D. No

The trochlear nuclei lie at the level of the:

A. Superior colliculi and red nucleus
B. Inferior colliculi and SCP decussation
C. Facial colliculi and MLF
D. Obex and pyramidal decussation

B. Inferior colliculi and SCP decussation

Which cranial nerve exits the brainstem dorsally and has crossed fibers?

A. Oculomotor nerve
B. Abducens nerve
C. Trochlear nerve
D. Trigeminal nerve

C. Trochlear nerve

Trochlear nerves are particularly susceptible to compression from:

A. Cerebellar tumors
B. Pituitary adenomas
C. ICA aneurysms
D. Vestibular schwannomas

A. Cerebellar tumors

The abducens nerve exits the dura and enters:

A. Meckel’s cave
B. Internal auditory meatus
C. Cavernous sinus
D. Dorello’s canal

D. Dorello’s canal

The abducens nerve is especially susceptible to injury from:

A. Lateral brain shift and high ICP
B. Downward traction and high ICP
C. Basilar thrombosis and low ICP
D. Optic nerve edema and low ICP

B. Downward traction and high ICP

From distal to proximal, causes of diplopia include fracture, then:

A. NMJ, muscles, CN palsies
B. CN palsies, muscles, NMJ
C. Muscles, NMJ, CN palsies
D. CN palsies, NMJ, muscles

C. Muscles, NMJ, CN palsies

Injury to an extraocular muscle most directly causes:

A. Dysconjugate gaze
B. Monocular blindness
C. Miosis
D. Visual field loss

A. Dysconjugate gaze

Abnormal lateral deviation of one eye is called:

A. Esotropia
B. Hypertropia
C. Phoria
D. Exotropia

D. Exotropia

Abnormal medial deviation of one eye is called:

A. Exotropia
B. Esotropia
C. Hypertropia
D. Amblyopia

B. Esotropia

Vertical deviation of one eye is called:

A. Esotropia
B. Exotropia
C. Hypertropia
D. Phoria

C. Hypertropia

A penlight shone at both eyes shows asymmetric corneal reflections. This suggests:

A. Subtle dysconjugate gaze
B. Papilledema
C. Afferent pupillary defect
D. Monocular blindness

A. Subtle dysconjugate gaze

A mild latent weakness revealed only when one eye is covered is called:

A. Exotropia
B. Hypertropia
C. Amblyopia
D. Phoria

D. Phoria

Amblyopia is:

A. Vertical misalignment
B. Decreased vision in one eye
C. Latent ocular drift
D. Diplopia on lateral gaze

B. Decreased vision in one eye

With a complete CN III palsy, the eye can still perform:

A. Abduction, depression, intorsion
B. Adduction, elevation, extorsion
C. Abduction, elevation, extorsion
D. Adduction, depression, intorsion

A. Abduction, depression, intorsion

Injury to the oculomotor nerve causes _____ of the pupil.

A. Constriction
B. Hippus
C. Normal size
D. Dilation

D. Dilation

Diplopia that is worse when looking at near objects rather than far objects suggests:

A. Trochlear palsy
B. Oculomotor palsy
C. Abducens palsy
D. Vestibular dysfunction

B. Oculomotor palsy

Diagonal diplopia that worsens when looking up and medially is most consistent with:

A. Abducens palsy
B. Trochlear palsy
C. Oculomotor palsy
D. Horner syndrome

C. Oculomotor palsy

Herniation of the medial temporal lobe over the tentorium cerebelli can compress the:

A. Oculomotor nerve
B. Optic tract
C. Trochlear nerve
D. Trigeminal nerve

A. Oculomotor nerve

In all suspected cases of oculomotor nerve palsy, which studies should be ordered?

A. EEG and lumbar puncture
B. EMG and NCS
C. CT perfusion and PET
D. CTA and MRA

D. CTA and MRA

Aneurysmal oculomotor palsy classically involves the:

A. Corneal reflex
B. Pupil
C. Facial sensation
D. Visual field

B. Pupil

Pupil-sparing oculomotor palsy is most likely caused by:

A. Uncal herniation
B. Cavernous sinus tumor
C. Diabetes or microvascular neuropathy
D. Posterior communicating aneurysm

C. Diabetes or microvascular neuropathy

A patient has ptosis, a “down and out” eye, and a dilated pupil. The most concerning cause is:

A. Posterior communicating aneurysm
B. Thyroid eye disease
C. Orbital floor fracture
D. Myasthenia gravis

A. Posterior communicating aneurysm

Horizontal diplopia after elevated intracranial pressure most likely reflects injury to:

A. Trochlear nerve
B. Oculomotor nerve
C. Optic nerve
D. Abducens nerve

D. Abducens nerve

The oculomotor nuclei are located at the level of the:

A. Superior colliculi and red nuclei
B. Inferior colliculi and SCP decussation
C. Facial colliculi and vestibular nuclei
D. Obex and pyramidal decussation

A. Superior colliculi and red nuclei

Relative to the cerebral aqueduct, the oculomotor nuclei lie:

A. Dorsal to tectum
B. Lateral to crus cerebri
C. Ventral to periaqueductal gray
D. Within the red nucleus

C. Ventral to periaqueductal gray

The abducens nuclei lie:

A. In the rostral midbrain
B. In the upper medulla
C. In the lateral tegmentum
D. On the floor of the fourth ventricle

D. On the floor of the fourth ventricle

The abducens nuclei are located in the:

A. Upper/mid pons
B. Mid/lower pons
C. Upper medulla
D. Cervicomedullary junction

B. Mid/lower pons

Which is a supranuclear cause of diplopia?

A. Orbital fracture
B. Oculomotor palsy
C. Internuclear ophthalmoplegia
D. Myasthenia gravis

C. Internuclear ophthalmoplegia

Which is also listed as a supranuclear cause of diplopia?

A. Skew deviation
B. Superior oblique myositis
C. Cavernous sinus lesion
D. Thyroid eye disease

A. Skew deviation

Which additional category is included among supranuclear causes of diplopia in this material?

A. Neuromuscular junction disease
B. Ingestion of toxins
C. Orbital pseudotumor
D. Ocular trauma

B. Ingestion of toxins

In mild dysconjugate gaze, patients may have only:

A. Complete ophthalmoplegia
B. Monocular blindness
C. Polyopia
D. Visual blurring

D. Visual blurring

Monocular diplopia or polyopia is not caused by:

A. Ophthalmologic disease
B. Visual cortex disorders
C. Eye movement abnormalities
D. Psychiatric conditions

C. Eye movement abnormalities

In oculomotor nerve palsy, the eye typically rests in a:

A. Down and out position
B. Up and out position
C. Down and in position
D. Midline fixed position

A. Down and out position

Complete ptosis requiring manual lid elevation is most suggestive of:

A. Trochlear palsy
B. Horner syndrome
C. Oculomotor palsy
D. Abducens palsy

C. Oculomotor palsy

Trochlear nerve palsy produces vertical diplopia because of loss of:

A. Elevation and extorsion
B. Adduction and elevation
C. Depression and extorsion
D. Depression and intorsion

D. Depression and intorsion

A patient improves diplopia by looking up and tilting the head away from the affected eye. This pattern suggests:

A. Oculomotor palsy
B. Trochlear palsy
C. Abducens palsy
D. Internuclear ophthalmoplegia

B. Trochlear palsy

Vertical diplopia in trochlear nerve palsy is usually worst when the eye looks:

A. Downward and nasally
B. Upward and temporally
C. Straight ahead only
D. Laterally and upward

A. Downward and nasally

Which finding supports trochlear nerve palsy?

A. Affected eye has esotropia
B. Diplopia improves on downgaze
C. Affected eye has hypertropia
D. Head tilt toward lesion helps

C. Affected eye has hypertropia

A patient sees two pen lines, with the lower line tilted, and has had a subtle compensatory head tilt since childhood but diplopia in adulthood. The best diagnosis is:

A. Acute abducens palsy
B. Myasthenia gravis
C. Oculomotor fascicular lesion
D. Congenital trochlear palsy

D. Congenital trochlear palsy

Vertical disparity of the eyes due to a supranuclear lesion is called:

A. Esotropia
B. Skew deviation
C. Exotropia
D. Phoria

B. Skew deviation

Skew deviation can result from lesions in the:

A. Cerebellum, brainstem, or inner ear
B. Orbit, retina, or lens
C. Cortex, chiasm, or tract
D. Pons, cord, or cortex

A. Cerebellum, brainstem, or inner ear

Lesions of the abducens nerve classically produce:

A. Vertical diplopia
B. Monocular diplopia
C. Horizontal diplopia
D. Torsional diplopia

C. Horizontal diplopia

Diplopia that improves at near but worsens at distance most strongly suggests:

A. Oculomotor palsy
B. Trochlear palsy
C. Abducens palsy
D. Horner syndrome

C. Abducens palsy

Diplopia that worsens when the affected eye abducts is most consistent with:

A. Trochlear palsy
B. Abducens palsy
C. Oculomotor palsy
D. Skew deviation

B. Abducens palsy

The abducens nerve is especially vulnerable to:

A. Downward traction from elevated ICP
B. Medial traction from aneurysm
C. Upward herniation from edema
D. Lateral stretch from trauma

A. Downward traction from elevated ICP

A pontine infarct affecting abducens pathways most likely causes:

A. Contralateral adduction weakness
B. Bilateral ptosis
C. Ipsilateral abduction weakness
D. Contralateral vertical diplopia

C. Ipsilateral abduction weakness

A lesion of the abducens nucleus may also produce facial weakness because of nearby involvement of:

A. CN V nucleus
B. CN VII nucleus
C. CN IX nucleus
D. CN XII nucleus

B. CN VII nucleus

Light entering one eye activates retinal ganglion cells that project to:

A. The ipsilateral optic tract
B. The contralateral optic tract
C. Both optic tracts
D. The lateral geniculate only

C. Both optic tracts

The pupillary light reflex travels centrally in the _____ pathway through the _____ of the superior colliculus.

A. Geniculocalcarine; tectum
B. Extrageniculate; brachium
C. Retinogeniculate; crus
D. Spinothalamic; tegmentum

B. Extrageniculate; brachium

The pupillary light reflex reaches the:

A. Pretectal area
B. Lateral geniculate body
C. Superior salivatory nucleus
D. Solitary nucleus

A. Pretectal area

Relative to the oculomotor nuclei, the Edinger-Westphal nuclei lie:

A. Ventral and posterior
B. Lateral and inferior
C. Dorsal and anterior
D. Medial and caudal

C. Dorsal and anterior

Which list gives all three components of accommodation?

A. Dilation, divergence, blinking
B. Constriction, lens accommodation, convergence
C. Miosis, abduction, convergence
D. Adduction, constriction, tearing

B. Constriction, lens accommodation, convergence

The accommodation response is initiated by visual signals relayed to the:

A. Pretectal area
B. Superior colliculus
C. Visual cortex
D. Red nucleus

C. Visual cortex

The descending sympathetic pathway for pupillary dilation activates preganglionic neurons in the:

A. Dorsal horn
B. Edinger-Westphal nucleus
C. Intermediolateral column
D. Ciliary ganglion

C. Intermediolateral column

Preganglionic sympathetic fibers reach the paravertebral chain through the:

A. Gray rami communicantes
B. White rami communicantes
C. Internal carotid plexus
D. Dorsal roots

B. White rami communicantes

Postganglionic sympathetic fibers to the pupillary dilator arise from the:

A. Ciliary ganglion
B. Pterygopalatine ganglion
C. Stellate ganglion
D. Superior cervical ganglion

D. Superior cervical ganglion

Postganglionic sympathetic fibers ascend to the cavernous sinus and then innervate the:

A. Pupillary constrictor muscle
B. Ciliary muscle
C. Pupillary dilator muscle
D. Medial rectus muscle

C. Pupillary dilator muscle

The sympathetic pathway also innervates Müller’s muscle, which:

A. Constricts the pupil
B. Elevates the upper eyelid
C. Depresses the lower eyelid
D. Adducts the globe

B. Elevates the upper eyelid

Asymmetry of pupil size is called:

A. Anisocoria
B. Amblyopia
C. Astigmatism
D. Hemianopia

A. Anisocoria

Injury to the Edinger-Westphal nuclei can cause a:

A. Bilaterally constricted pupil
B. Unilaterally dilated pupil
C. Bilateral Marcus Gunn pupil
D. Small reactive pupil

B. Unilaterally dilated pupil

Ptosis in Horner syndrome is due to denervation of:

A. Levator palpebrae superioris
B. Superior rectus
C. Müller’s muscle
D. Orbicularis oculi

C. Müller’s muscle

Miosis in Horner syndrome is caused by loss of sympathetic input to the:

A. Pupillary constrictor
B. Pupillary dilator
C. Ciliary muscle
D. Superior tarsal muscle

B. Pupillary dilator

Anisocoria that is more obvious in the dark suggests:

A. Oculomotor lesion
B. Marcus Gunn pupil
C. Horner syndrome
D. Pontine lesion

C. Horner syndrome

Pupillary dilation after hydroxyamphetamine drops indicates a:

A. Postganglionic lesion
B. Preganglionic lesion
C. Optic tract lesion
D. Midbrain lesion

B. Preganglionic lesion

The absence of anhidrosis favors a _____ sympathetic lesion.

A. Central
B. Preganglionic
C. Diffuse
D. Postganglionic

D. Postganglionic

Bilateral small but light-reactive pupils are most consistent with lesions of the:

A. Midbrain
B. Pons
C. Optic nerves
D. Cavernous sinus

B. Pons

An absent direct response with a normal consensual response is characteristic of:

A. Horner syndrome
B. Argyll Robertson pupils
C. Marcus Gunn pupils
D. Oculomotor palsy

C. Marcus Gunn pupils

Marcus Gunn pupils result from injury to the:

A. Optic nerve, retina, or eye
B. Oculomotor nerve, iris, or lens
C. Optic chiasm, tract, or cortex
D. Pons, medulla, or cerebellum

A. Optic nerve, retina, or eye

A lesion at or behind the optic chiasm would produce Marcus Gunn pupils:

A. Always
B. Usually
C. Sometimes
D. Never

D. Never

The best bedside test for Marcus Gunn pupils is the:

A. Doll’s eye test
B. Swinging flashlight test
C. Cover-uncover test
D. Head impulse test

B. Swinging flashlight test

During the swinging flashlight test, paradoxical dilation every few seconds suggests:

A. Horner syndrome
B. Pontine pupils
C. Marcus Gunn pupils
D. Oculomotor palsy

C. Marcus Gunn pupils

A patient with optic neuritis has a relative afferent pupillary defect. Can optic nerve or retinal disease itself explain anisocoria?

A. Yes, commonly
B. Only if bilateral
C. Only with retinal detachment
D. No

D. No

Benign anisocoria is usually defined by a pupil asymmetry of:

A. Less than 0.6 mm
B. Less than 1.5 mm
C. Greater than 0.6 mm
D. Greater than 2.0 mm

A. Less than 0.6 mm

A patient found unresponsive has bilateral pinpoint pupils. Which intoxication is most likely?

A. Anticholinergics
B. Cocaine
C. Opiates
D. Amphetamines

C. Opiates

Barbiturate overdose classically causes:

A. Bilateral fixed dilated pupils
B. Bilateral small pupils
C. Unilateral blown pupil
D. Alternating anisocoria

B. Bilateral small pupils

A dilated pupil constricts with 1% pilocarpine. This finding supports:

A. Muscarinic blockade
B. Sympathetic overactivity
C. Optic neuropathy
D. Parasympathetic lesion

D. Parasympathetic lesion

The classic light-near dissociation pupil associated with neurosyphilis is the:

A. Argyll Robertson pupil
B. Adie tonic pupil
C. Marcus Gunn pupil
D. Horner pupil

A. Argyll Robertson pupil

Degeneration of the ciliary ganglion or postganglionic parasympathetic neurons causes a mid-dilated pupil known as:

A. Argyll Robertson pupil
B. Adie myotonic pupil
C. Marcus Gunn pupil
D. Midbrain corectopia

B. Adie myotonic pupil

A pupil that is irregular and off-center suggests the rare disorder:

A. Adie myotonic pupil
B. Argyll Robertson pupil
C. Midbrain corectopia
D. Horner syndrome

C. Midbrain corectopia

Opening of the eye is mediated primarily by:

A. Levator and Müller muscles
B. Orbicularis and levator
C. Superior rectus and levator
D. Orbicularis and superior tarsal

A. Levator and Müller muscles

Eye closure is produced by the _____ muscle innervated by _____.

A. Levator palpebrae; CN III
B. Müller; sympathetics
C. Frontalis; CN VII
D. Orbicularis oculi; CN VII

D. Orbicularis oculi; CN VII

Mild ptosis is most suggestive of:

A. Myasthenia gravis
B. Horner syndrome
C. Oculomotor palsy
D. Facial nerve palsy

B. Horner syndrome

Ptosis that worsens with sustained upgaze most strongly suggests:

A. Horner syndrome
B. Oculomotor lesion
C. Myasthenia gravis
D. Cavernous sinus syndrome

B. Oculomotor lesion

Bilateral ptosis without loss of consciousness suggests a dorsal lesion affecting the:

A. Central caudal nucleus
B. Red nucleus
C. Edinger-Westphal nucleus
D. Pretectal area

A. Central caudal nucleus

The cavernous sinus lies between the _____ and _____ layers of dura.

A. Arachnoid and meningeal
B. Periosteal and dural
C. Dural and pial
D. Periosteal and arachnoid

B. Periosteal and dural

Within the cavernous sinus, the nerve closest to the carotid siphon is the:

A. Oculomotor nerve
B. Trochlear nerve
C. Abducens nerve
D. Ophthalmic nerve

C. Abducens nerve

The orbital apex is the region where orbital _____ converge.

A. Nerves, arteries, and veins
B. Muscles, nerves, and lens
C. Veins, ducts, and retina
D. Arteries, chiasm, and veins

A. Nerves, arteries, and veins

Cavernous sinus syndrome classically disrupts:

A. CN II, III, IV
B. CN III, V1, V2
C. CN II, IV, VI
D. CN III, IV, VI

D. CN III, IV, VI

The first nerve typically affected by a cavernous carotid aneurysm is the:

A. Oculomotor nerve
B. Trochlear nerve
C. Abducens nerve
D. Optic nerve

C. Abducens nerve

Supranuclear output from CN III, IV, and VI systems generates which eye movements?

A. Horizontal, vertical, vergence
B. Saccadic, smooth, vestibular
C. Horizontal, torsional, pursuit
D. Fixation, blinking, vergence

A. Horizontal, vertical, vergence

Stable viewing of a moving target is mediated by:

A. Vergence
B. Saccades
C. Vestibulo-ocular reflex
D. Smooth pursuit

D. Smooth pursuit

The oculomotor and trochlear nuclei are in the _____, whereas the abducens nucleus is in the _____.

A. Pons; medulla
B. Medulla; midbrain
C. Midbrain; pons
D. Midbrain; medulla

C. Midbrain; pons

The tract interconnecting eye movement nuclei with vestibular nuclei is the:

A. Medial longitudinal fasciculus
B. Trigeminothalamic tract
C. Medial lemniscus
D. Spinothalamic tract

A. Medial longitudinal fasciculus

A dilated pupil fails to constrict after 1% pilocarpine. This most strongly suggests:

A. Preganglionic parasympathetic lesion
B. Muscarinic blockade
C. Adie myotonic pupil
D. Edinger-Westphal injury

B. Muscarinic blockade

_____ are rapid eye movements reaching velocities of up to 700° per second

Saccades

_____ eye movements maintain fused fixation by both eyes as targets move toward or away from the viewer

Vergence

_____ is a rhythmic form of reflex eye movements composed of slow eye movements in one direction interrupted repeatedly by fast, saccade-like eye movements in the opposite direction.

Nystagmus