Neuro-ophthalmology and pupils: painful Horner syndrome: practice question

A Ophthalmology question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Ophthalmology · Neuro-ophthalmology and pupils: painful Horner syndrome

Sample item

A 38-year-old man develops sudden right neck and facial pain after vigorous neck manipulation, followed by right ptosis and a small pupil. Sweating is preserved on the forehead. What is the most likely cause?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

D. Internal carotid artery dissection

A carotid dissection damages the sympathetic fibres that run on the carotid wall, giving a postganglionic Horner syndrome with ipsilateral pain. Sweating of the forehead is preserved because the fibres to the sweat glands travel on the external carotid. Urgent vascular imaging is needed to prevent stroke.

Option by option

  • A. Thyroid eye disease

    Thyroid eye disease causes lid retraction and proptosis and not ptosis with a small pupil.

  • B. Brainstem lateral medullary infarct

    A lateral medullary infarct gives a central Horner syndrome with vertigo and crossed sensory loss.

  • C. Pancoast tumour of the lung apex

    A Pancoast tumour causes a preganglionic Horner syndrome with shoulder and arm pain and anhidrosis of the face.

  • D. Internal carotid artery dissection (correct)

    Correct. Painful postganglionic Horner syndrome after neck trauma suggests internal carotid dissection.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this Ophthalmology question

What is the answer to this Ophthalmology question?

The best answer is D, Internal carotid artery dissection. A carotid dissection damages the sympathetic fibres that run on the carotid wall, giving a postganglionic Horner syndrome with ipsilateral pain.

Why is "Thyroid eye disease" not the answer?

Thyroid eye disease causes lid retraction and proptosis and not ptosis with a small pupil.

Why is "Brainstem lateral medullary infarct" not the answer?

A lateral medullary infarct gives a central Horner syndrome with vertigo and crossed sensory loss.

Why is "Pancoast tumour of the lung apex" not the answer?

A Pancoast tumour causes a preganglionic Horner syndrome with shoulder and arm pain and anhidrosis of the face.

What concept does this question test?

It tests Neuro-ophthalmology and pupils: painful Horner syndrome in Ophthalmology. Sweating of the forehead is preserved because the fibres to the sweat glands travel on the external carotid. Urgent vascular imaging is needed to prevent stroke.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Neuro-ophthalmology and pupils: painful Horner syndrome?

Group the red eye by what to examine and what the pupil does. Then use the flashcards and the other Ophthalmology questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.