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Quiz: The Painful Eye That Won't Move

Test your understanding of this case with 16 questions.

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Case Information
Review the case details while answering questions

PATIENT DEMOGRAPHICS

84-year-old female

PRESENTING COMPLAINT

Progressive double vision (both vertical and horizontal) and deep left orbital pain over several weeks.

EXAMINATION FINDINGS

Visual Acuity: Visual acuity testing was limited by ptosis and diplopia but was estimated at approximately 6/9 bilaterally. Formal documentation was incomplete at initial presentation.

Pupils: Left pupil involvement suspected (CN III palsy with possible pupillary involvement)

Fundus: No papilloedema or retinal abnormalities noted

INVESTIGATIONS

Clinical Photographs - Ptosis and Eye Position: Frontal view demonstrates left upper lid ptosis. Close-up examination shows the left eye in a position consistent with CN III palsy (eye down and out position).

Clinical photographs showing left ptosis and abnormal eye position at rest

Clinical photographs showing left ptosis and abnormal eye position at rest

Extraocular Movement Assessment: Systematic assessment of eye movements using fixation targets demonstrates severe restriction in multiple directions of gaze. Left eye shows marked limitation in elevation, depression, and adduction (CN III palsy) with impaired abduction (CN VI involvement). Multiple positions of gaze documented showing the extent of ophthalmoplegia.

Extraocular movement testing with fixation targets demonstrating left CN III and CN VI palsies with restricted motility in all directions

Extraocular movement testing with fixation targets demonstrating left CN III and CN VI palsies with restricted motility in all directions

CT Brain (Axial Views - Non-contrast and Contrast Comparison): Axial CT imaging in both non-contrast and contrast-enhanced phases reveals a cavernous sinus lesion consistent with an internal carotid artery aneurysm. The contrast-enhanced images show characteristic filling of the aneurysmal sac, confirming the vascular nature of the lesion. The location within the cavernous sinus explains the multiple cranial nerve palsies.

CT brain comparison: Non-contrast (left) and contrast-enhanced (right) axial views demonstrating left cavernous sinus internal carotid artery aneurysm with contrast filling

CT brain comparison: Non-contrast (left) and contrast-enhanced (right) axial views demonstrating left cavernous sinus internal carotid artery aneurysm with contrast filling

Neurological Examination: Pain distribution corresponds to left ophthalmic division (V1) of trigeminal nerve. Features suggestive of Horner's syndrome (miosis, mild ptosis) from sympathetic fibre involvement.

Question 1 of 16

Which cranial nerve palsy explains the inability of the left eye to elevate, depress, or adduct?

Question 2 of 16

Which cranial nerve palsy explains impaired abduction of the left eye?

Question 3 of 16

What is the likely cause of the patient's ptosis?

Question 4 of 16

In this patient, CN III palsy and Horner's syndrome are both present simultaneously. Which pupillary finding would specifically confirm the Horner's component?

Question 5 of 16

What structure is most likely affected to cause the combination of CN III, CN VI, and trigeminal V1 involvement?

Question 6 of 16

The patient reports severe deep orbital pain. Which nerve mediates this symptom?

Question 7 of 16

What is the most likely underlying pathology in this patient?

Question 8 of 16

On CT contrast images, what would you expect to see in the cavernous sinus aneurysm?

Question 9 of 16

Which of the following is NOT located in the cavernous sinus?

Question 10 of 16

What is the gold standard imaging modality for confirming a cavernous sinus aneurysm?

Question 11 of 16

A cavernous sinus ICA aneurysm is located in the extradural compartment. What is the most likely complication if this aneurysm ruptures?

Question 12 of 16

What is the most appropriate initial management strategy for a cavernous sinus internal carotid aneurysm?

Question 13 of 16

What is the most likely diagnosis?

Question 14 of 16

The following is an appropriate management step: Urgent neurovascular/interventional neuroradiology referral

Question 15 of 16

What is the most likely diagnosis?

Question 16 of 16

The following is an appropriate management step: Urgent neurovascular/interventional neuroradiology referral