{"id":1005,"date":"2024-01-24T15:00:00","date_gmt":"2024-01-24T15:00:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=1005"},"modified":"2025-10-01T11:39:31","modified_gmt":"2025-10-01T19:39:31","slug":"usmle-step-2-question-of-the-day-double-vision","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Double vision"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#B_Stretching_and_injury_to_a_cranial_nerve_over_the_petrous_portion_of_the_temporal_bone\" >B. Stretching and injury to a cranial nerve over the petrous portion of the temporal bone<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#A_Compression_of_a_cranial_nerve_by_an_aneurysm_in_the_posterior_communicating_artery\" >A.&nbsp;Compression of a cranial nerve by an aneurysm in the posterior communicating artery&nbsp;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#C_Thrombosis_of_the_cavernous_sinus\" >C. Thrombosis of the cavernous sinus<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#D_Occlusion_of_the_posterior_cerebral_artery\" >D. Occlusion of the posterior cerebral artery<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#E_Occlusion_of_the_posterior_inferior_cerebellar_artery\" >E. Occlusion of the posterior inferior cerebellar artery<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\/#Major_takeaway\" >Major takeaway<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;<strong><em>Today&#8217;s case involves a 65-year-old woman in the emergency department, presenting with double vision, headache, and escalating symptoms. With a history of hypertension and amlodipine use, ophthalmologic examination uncovers bilateral papilledema and right eye medial deviation. Can you identify the most likely cause of her distressing double vision in this compelling medical scenario?<\/em><\/strong><\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 65-year-old woman comes to the emergency department complaining of double vision and headache, accompanied by nausea and vomiting. Her symptoms started three days ago and have worsened since the onset. Past medical history is significant for hypertension, for which she takes amlodipine. Temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 90\/min, respirations are 15\/min, and blood pressure is 110\/75 mmHg. Ophthalmologic examination reveals bilateral papilledema and medial deviation of the right eye. Abduction of the right eye is impaired. All other eye movements are normal in both the eyes. Which of the following is the most likely cause of this patient\u2019s double vision?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Compression of a cranial nerve by an aneurysm in the posterior communicating artery&nbsp;<\/strong><strong>B. Stretching and injury to a cranial nerve over the petrous portion of the temporal bone<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Thrombosis of the cavernous sinus<br><\/strong><br><strong>D. Occlusion of the posterior cerebral artery<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Occlusion of the posterior inferior cerebellar artery<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Stretching_and_injury_to_a_cranial_nerve_over_the_petrous_portion_of_the_temporal_bone\"><\/span><strong>B. Stretching and injury to a cranial nerve over the petrous portion of the temporal bone<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t A, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Compression_of_a_cranial_nerve_by_an_aneurysm_in_the_posterior_communicating_artery\"><\/span><strong>A.&nbsp;<\/strong>Compression of a cranial nerve by an aneurysm in the posterior communicating artery&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Aneurysm in the posterior communicating artery can compress the oculomotor nerve. This causes the eye to deviate down and out and the affected pupil to dilate (mydriasis). None of this is seen in this patient. Instead, this patient is most likely having CN VI palsy due to increased intracranial pressure.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_Thrombosis_of_the_cavernous_sinus\"><\/span><strong>C. Thrombosis of the cavernous sinus<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Cavernous sinus thrombosis can cause CN VI palsy, but this condition is usually associated with proptosis, orbital swelling, and other cranial nerve palsies (e.g., CN III, CN IV).<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_Occlusion_of_the_posterior_cerebral_artery\"><\/span><strong>D. Occlusion of the posterior cerebral artery<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>The posterior cerebral artery supplies the medial midbrain. Its occlusion causes Weber syndrome, which is characterized by oculomotor nerve dysfunction with associated contralateral hemiparesis, which are not seen in this patient.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_Occlusion_of_the_posterior_inferior_cerebellar_artery\"><\/span><strong>E. Occlusion of the posterior inferior cerebellar artery<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Occlusion of the posterior inferior cerebellar artery causes lateral medullary syndrome (Wallenberg syndrome), which is characterized by loss of the gag reflex, dysphagia, hoarseness, and loss of pain and temperature sensation of the face and the contralateral side of the body. This patient does not have Wallenberg syndrome.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient is exhibiting signs and symptoms of increased intracranial pressure (ICP) including papilledema, nausea, vomiting and headache. The ophthalmologic findings of diplopia and dysfunction of lateral gaze of the right eye are concerning for abducens nerve (CN VI) palsy. This patient most likely has a space-occupying lesion that is stretching and injuring the CN VI for which imaging (e.g. MRI) is warranted.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The abducens nerve (CN VI) is a pure motor nerve that supplies the lateral rectus muscle, which is responsible for abducting the eye. It exits the midbrain at the level of pontomedullary junction, then crosses over the petrous apex of the temporal bone, where it enters the cavernous sinus. It then travels towards the lateral rectus muscle.&nbsp;CN VI palsy causes loss of lateral movement of the affected eye, leaving the action of the medial rectus muscle unopposed, which leads to medial deviation of the eye and resulting diplopia. Diplopia usually worsens when looking towards the side of the lesion and resolves when looking away from the lesion.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"840\" height=\"448\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/abducens-nerve-palsy.png\" alt=\"abducens nerve palsy illustration\" class=\"wp-image-1010\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/abducens-nerve-palsy.png 840w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/abducens-nerve-palsy.png?resize=300,160 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/abducens-nerve-palsy.png?resize=768,410 768w\" sizes=\"auto, (max-width: 840px) 100vw, 840px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">The most common cause of abducens nerve palsy is increased ICP, which can stretch the nerve as it crosses over the petrous apex. Common causes of increased ICP include space-occupying lesions (e.g., tumor, abscess). Other causes of CN VI palsy include head trauma, cavernous sinus thrombosis, demyelinating disorders, ischemic vascular disease and mastoiditis or otitis media, which may spread to the petrous portion of the temporal bone and damage the abducens nerve.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"838\" height=\"468\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/petrous-portion-of-the-temporal-bone.png\" alt=\"illustration of the petrous portion of the temporal bone\" class=\"wp-image-1011\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/petrous-portion-of-the-temporal-bone.png 838w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/petrous-portion-of-the-temporal-bone.png?resize=300,168 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/petrous-portion-of-the-temporal-bone.png?resize=768,429 768w\" sizes=\"auto, (max-width: 838px) 100vw, 838px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_takeaway\"><\/span><strong>Major takeaway<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Increased intracranial pressure can stretch and injure the abducens nerve (CN VI) as it passes over the petrous apex of the temporal bone. The resultant CN VI palsy causes lateral gaze dysfunction of the ipsilateral eye.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Graham C, Mohseni M. Abducens Nerve Palsy. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:&nbsp;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482177\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482177\/<\/a>&nbsp;\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013<br><em><br><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;<\/strong><\/em><em><strong>Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?w=700\" alt=\"Ace your clerkships with clinical practice videos on Osmosis. Watch now.\" class=\"wp-image-544\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n","protected":false},"excerpt":{"rendered":"<p>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;s case involves a 65-year-old woman in the emergency department, presenting with double vision, headache, and escalating symptoms. With a history of hypertension and amlodipine use, ophthalmologic examination uncovers bilateral papilledema and right eye medial deviation. Can you identify the most likely cause of [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":1012,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1370,45],"tags":[],"class_list":["post-1005","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Double vision - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-double-vision\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Double vision - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;s case involves a 65-year-old woman in the emergency department, presenting with double vision, headache, and escalating symptoms. With a history of hypertension and amlodipine use, ophthalmologic examination uncovers bilateral papilledema and right eye medial deviation. 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