okap banik neuro okap questions
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Neuro‐Ophthalmology OKAP Review Questions 2012
Rudrani Banik, M.D.
Associate Adjunct Surgeon
The New York Eye & Ear Infirmary
1. A 28‐year‐old obese woman complains of transient visual loss lasting seconds in the right eye when rising from a bent position. Examination reveals normal acuity OU withfundoscopy as shown. What is the best course of action?
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1. A 28‐year‐old obese woman complains of transient visual loss lasting seconds in the right eye when rising from a bent position. Examination reveals normal acuity OU with fundoscopy as shown. What is the best course of action?
A. Medical therapy for intracranial hypertension; no need for neuroimaging
B. CT of the brain, then medical therapy for intracranial hypertension
C. MRI and lumbar puncture, then medical therapy for intracranial hypertension
D. CT of the brain, then a shunting procedure for intracranial hypertension
1. A 28‐year‐old obese woman complains of transient visual loss lasting seconds in the right eye when rising from a bent position. Examination reveals normal acuity OU with fundoscopy as shown below. What is the best course of action?
A. Medical therapy for intracranial hypertension; no need for neuroimaging
B. CT of the brain, then medical therapy for intracranial hypertension
C. MRI and lumbar puncture, then medical therapy for intracranial hypertension
D. CT of the brain, then a shunting procedure for intracranial hypertension
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Case #1a
2. A 68‐year‐old obese woman complains of transient visual loss lasting seconds in the right eye when rising from a bent position. Examination reveals normal acuity OU withfundoscopy as shown below. What is the best course of action?
A. Medical therapy for intracranial hypertension; no need for neuroimaging
B. CT of the brain, then medical therapy for intracranial hypertension
C. MRI and lumbar puncture, then medical therapy for intracranial hypertension
D. Blood pressure measurement
Case #1a
2. A 68‐year‐old obese woman complains of transient visual loss lasting seconds in the right eye when rising from a bent position. Examination reveals normal acuity OU withfundoscopy as shown below. What is the best course of action?
A. Medical therapy for intracranial hypertension; no need for neuroimaging
B. CT of the brain, then medical therapy for intracranial hypertension
C. MRI and lumbar puncture, then medical therapy for intracranial hypertension
D. Blood pressure measurement
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3. A 35‐year‐old woman presents with sudden painful loss of vision of her right eye. Her examination reveals vision of 20/80 OD and 20/20 OS. Pupils demonstrate an afferent pupillary defect of the right eye. A dense inferior altitudinal defect encroaches on central fixation OD, and the left visual field is normal. The remainder of the examination is normal. Fundusexamination of the right eye is shown.
3. How would you counsel this patient?
A. She is unlikely to have optic neuritis because the optic nerve on examination is normal; however, she needs an MRI scan of the orbits to rule out a tumor.
B. She has optic neuritis and should begin one of the proven treatments for multiple sclerosis (MS) to prevent its onset.
C. She should have an MRI scan to rule out a tumor, as well as take oral corticosteroids to assess the benefit.
D. She has optic neuritis and should have an MRI scan of the brain to assess her risk for MS.
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3. How would you counsel this patient?
A. She is unlikely to have optic neuritis because the optic nerve on examination is normal; however, she needs an MRI scan of the orbits to rule out a tumor.
B. She has optic neuritis and should begin one of the proven treatments for multiple sclerosis (MS) to prevent its onset.
C. She should have an MRI scan to rule out a tumor, as well as take oral corticosteroids to assess the benefit.
D. She has optic neuritis and should have an MRI scan of the brain to assess her risk for MS.
4. The patient’s MRI results are shown. What is her long‐term risk for developing MS?
A. 25%
B. 50%
C. 72%
D. Insufficient evidence provided
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4. The patient’s MRI results are shown. What is her long‐term risk for developing MS?
A. 25%
B. 50%
C. 72%
D. Insufficient evidence provided
5. Based on the CHAMPS results, this patient’s treatment options include:
A. IV steroids only
B. Treatment with plasmapheresis
C. Treatment with interferon beta 1‐a (Avonex®)
D. Treatment with fingolimod(Gilenya®)
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5. Based on the CHAMPS results, this patient’s treatment options include:
A. IV steroids only
B. Treatment with plasmapheresis
C. Treatment with interferon beta 1‐a (Avonex®)
D. Treatment with fingolimod(Gilenya®)
6. Which of the following conditions involving the facial muscles is most likely to be unilateral?
A. Apraxia of eyelid opening
B. Hemifacial spasm
C. Miller‐Fisher syndrome
D. Benign essential blepharospasm
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6. Which of the following conditions involving the facial muscles is most likely to be unilateral?
A. Apraxia of eyelid opening
B. Hemifacial spasm
C. Miller‐Fisher syndrome
D. Benign essential blepharospasm
7. In this patient, what is the next step in appropriate management?
A. Obtain history of prior facial palsy; if positive, then no further management required
B. Obtain history of prior facial palsy; if negative, then no further management required
C. Treat with botulinum toxin
D. Treat with tegretol
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7. In this patient, what is the next step in appropriate management?
A. Obtain history of prior facial palsy; if positive, then no further management required
B. Obtain history of prior facial palsy; if negative, then no further management required
C. Treat with botulinum toxin
D. Treat with tegretol
8. A 78‐year‐old man with ischemic heart disease and hypertension experiences a single 10‐minute episode of painless visual loss in his left eye. He describes the episode as a "gray window shade" being pulled down and then released. Which is the most likely etiology of his visual loss?
A. migraine B. vertebrobasilar circulation insufficiencyC. Uhthoff phenomenonD. retinal artery embolus
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8. A 78‐year‐old man with ischemic heart disease and hypertension experiences a single 10‐minute episode of painless visual loss in his left eye. He describes the episode as a "gray window shade" being pulled down and then released. Which is the most likely etiology of his visual loss?
A. migraine B. vertebrobasilar circulation insufficiencyC. Uhthoff phenomenonD. retinal artery embolus
9. Which of the following tests would be leastappropriate for the previous patient?
A. MRI Brain with contrast
B. Doppler carotid ultrasound
C. ESR and CRP
D. Trans‐esophageal echocardiography
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9. Which of the following tests would be leastappropriate for the previous patient?
A. MRI Brain with contrast
B. Doppler carotid ultrasound
C. ESR and CRP
D. Trans‐esophageal echocardiography
10. A 50‐year‐old woman developed variable double vision 1 month ago and appears to have fatigable ptosis. She has no systemic symptoms. Which of the following statements is true?
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10. A 50‐year‐old woman developed variable double vision 1 month ago and appears to have fatigable ptosis. She has no systemic symptoms. Which of the following statements is true?
A. A normal anti‐acetylcholine receptor antibody level effectively rules out myasthenia gravis
B. Her risk of developing generalized myasthenia is about 85% over 2 years
C. The 50% occurrence of concomitant thyroid eye disease may complicate the diagnosis of myasthenia.
D. An improvement of 2 mm in ptosis following a 10‐minute ice application to the eyelid confirms the diagnosis of myasthenia.
10. A 50‐year‐old woman developed variable double vision 1 month ago and appears to have fatigable ptosis. She has no systemic symptoms. Which of the following statements is true?
A. A normal anti‐acetylcholine receptor antibody level effectively rules out myasthenia gravis
B. Her risk of developing generalized myasthenia is about 85% over 2 years
C. The 50% occurrence of concomitant thyroid eye disease may complicate the diagnosis of myasthenia.
D. An improvement of 2 mm in ptosis following a 10‐minute ice application to the eyelid confirms the diagnosis of myasthenia.
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11. Which of the following conditions does notpredispose an individual to specific intracranial lesions?
A. ataxia‐telangiectasia (Louis‐Bar)
B. racemose angioma (Wyburn‐Mason)
C. retinal angiomatosis (von Hippel‐Lindau)
D. tuberous sclerosis (Bourneville)
11. Which of the following conditions does notpredispose an individual to specific intracranial lesions?
A. ataxia‐telangiectasia (Louis‐Bar)
B. racemose angioma (Wyburn‐Mason)
C. retinal angiomatosis (von Hippel‐Lindau)
D. tuberous sclerosis (Bourneville)
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• 12. A 77‐year‐old hypertensive man complains of sudden loss of vision in the left eye. He is found to be 20/25 OD and light perception OS, with a dense left afferent pupillary defect.
Right fundus examination demonstrates a normal optic disc but a number of cotton‐wool spots. Examination of the left eyeis as shown.
• 12. A 77‐year‐old hypertensive man complains of sudden loss of vision in the left eye. He is found to be 20/25 OD and light perception OS, with a dense left afferent pupillary defect. Right fundus examination demonstrates a normal optic disc but a number of cotton‐wool spots. Examination of the left eye is as shown. What is the appropriate sequence of evaluation in this patient?
A. immediate erythrocyte sedimentation rate (ESR) and C‐reactive protein; the office to call patient with results
B. immediate ESR and C‐ reactive protein, then the institution of corticosteroids, followed by a temporal artery biopsy
C. immediate ESR and C‐reactive protein, then a temporal artery biopsy, followed by the institution of corticosteroids, depending on biopsy results
D. immediate ESR and C‐reactive protein, then the institution of corticosteroids; no biopsy necessary if clinical suspicion is high
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12. A 77‐year‐old hypertensive man complains of sudden loss of vision in the left eye. He is found to be 20/25 OD and light perception OS, with a dense left afferent pupillary defect. Right fundus examination demonstrates a normal optic disc but a number of cotton‐wool spots. Examination of the left eye is as shown. What is the appropriate sequence of evaluation in this patient?
A. immediate erythrocyte sedimentation rate (ESR) and C‐reactive protein; the office to call patient with results
B. immediate ESR and C‐ reactive protein, then the institution of corticosteroids, followed by a temporal artery biopsy
C. immediate ESR and C‐reactive protein, then a temporal artery biopsy, followed by the institution of corticosteroids, depending on biopsy results
D. immediate ESR and C‐reactive protein, then the institution of corticosteroids; no biopsy necessary if clinical suspicion is high
13. The medial orbital wall is composed of all of the following bones except:
A. ethmoid
B. Lacrimal
C. sphenoid
D. frontal
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13. The medial orbital wall is composed of all of the following bones except:
A. ethmoid
B. Lacrimal
C. sphenoid
D. frontal
14. The test least likely to be helpful in determining non‐organic visual loss is
A. Automated perimetry
B. Goldmann perimetry
C. Tangent screen perimetry
D. Vertical prism dissociation test
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14. The test least likely to be helpful in determining non‐organic visual loss is
A. Automated perimetry
B. Goldmann perimetry
C. Tangent screen perimetry
D. Vertical prism dissociation test
15. A 54‐year‐old woman reports visual loss in the right eye occurring over 3 days. Vision is no light perception in the right eye. What finding would suggest non‐organic visual loss?
A. An RAPD OD
B. no eye movements when a mirror moves over the right eye
C. an amaurotic pupil
D. no eye movements when a 6 D base‐out prism is placed over the right eye
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15. A 54‐year‐old woman reports visual loss in the right eye occurring over 3 days. Vision is no light perception in the right eye. What finding would suggest non‐organic visual loss?
A. An RAPD OD
B. eye movements when a mirror moves over the right eye
C. an amaurotic pupil
D. no eye movements when a 6 D base‐out prism is placed over the right eye
16. A 20‐year‐old, previously healthy, female complains of headache and has a fixed, dilated left pupil. Her examination is otherwise normal.
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16. A 20‐year‐old, previously healthy, female complains of headache and has a fixed, dilated left pupil. Her examination is otherwise normal. Which of the following is least likely to be helpful in the initial evaluation?
A. observation
B. dilute (0.125 %) pilocarpine
C. 1 % pilocarpine
D. Hydroxyamphetamine
16. A 20‐year‐old, previously healthy, female complains of headache and has a fixed, dilated left pupil. Her examination is otherwise normal. Which of the following is least likely to be helpful in the initial evaluation?
A. observation
B. dilute (0.125 %) pilocarpine
C. 1 % pilocarpine
D. Hydroxyamphetamine
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17. A horizontal gaze palsy is indicative of which of the following?
A. Middle cerebral artery infarction
B. a lesion of the ipsilateral frontal lobe
C. a lesion of the contralateral frontal lobe
D. damage to the pontine gaze centers
17. A horizontal gaze palsy is indicative of which of the following?
A. Middle cerebral artery infarction
B. a lesion of the ipsilateral frontal lobe
C. a lesion of the contralateral frontal lobe
D. damage to the pontine gaze centers
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Horizontal Gaze Pathways within Brainstem
• Abducens nucleus
• Sends axons to innervate ipsilateral lateral rectus
• Send axons through contralateral MLF to innervate contralateral medial rectus subnucleus
Horizontal Gaze Pathways within Brainstem
• Stimulation of Right abducens nucleus results in conjugate gaze to Right
• Stimulation of Left abducens nucleus results in conjugate gaze to Left
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18. The brainstem horizontal saccadic generator is the
A. nucleus reticularis tegmenti pontis
B. rostral interstitial nucleus of the medial longitudinal fasciculus
C. paramedian pontine reticular formation
D. interstitial nucleus of Cajal
17. The brainstem horizontal saccadic generator is the
A. nucleus reticularis tegmenti pontis
B. rostral interstitial nucleus of the medial longitudinal fasciculus
C. paramedian pontine reticular formation
D. interstitial nucleus of Cajal
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19. What is the clinical presentation of a nuclear third cranial nerve palsy?
A. Unilateral third cranial nerve palsy with ipsilateral ptosis
B. Complete unilateral third nerve palsy involving the pupils only
C. Complete unilateral third nerve palsy with contralateral superior rectus paresis and bilateral ptosis
D. Complete bilateral third nerve palsy with dilated pupil on one side only
19. What is the clinical presentation of a nuclear third cranial nerve palsy?
A. Unilateral third cranial nerve palsy with ipsilateral ptosis
B. Complete unilateral third nerve palsy involving the pupils only
C. Complete unilateral third nerve palsy with contralateral superior rectus paresis and bilateral ptosis
D. Complete bilateral third nerve palsy with dilated pupil on one side only
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CN III Nuclear Paresis
• Rare
• Bilateral ptosis
– involves central caudal nucleus which innervates BOTH levators
• Bilateral upgaze paresis
– Each superior rectus innervated by contralateral subnucleus
– As fibers cross, they also go through the other SR subnucleus
CN III Nuclear Paresis
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20. In an emergency room setting, which of the following imaging studies is the most appropriate for third cranial nerve palsy in a patient with the worst headache of his life?
20. In an emergency room setting, which of the following imaging studies is the most appropriate for third cranial nerve palsy in a patient with the worst headache of his life?
A. Contrast MRI Orbit for inflammatory orbital pseudotumor
B. Non‐contrast MRI brain for aneurysm
C. Non‐contrast CT head for subarachnoid hemorrhage
D. Non‐contrast Ct Orbit for hematoma
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20. In an emergency room setting, which of the following imaging studies is the most appropriate for third cranial nerve palsy in a patient with the worst headache of his life?
A. Contrast MRI Orbit for inflammatory orbital pseudotumor
B. Non‐contrast MRI brain for aneurysm
C. Non‐contrast CT head for subarachnoid hemorrhage
D. Non‐contrast Ct Orbit for hematoma
21. The most important factor in determining the workup of a patient with acute third nerve palsy is:
A. age of patient
B. pupil involvement
C. presence or absence of pain
D. visual acuity
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21. The most important factor in determining the workup of a patient with acute third nerve palsy is:
A. age of patient
B. pupil involvement
C. presence or absence of pain
D. visual acuity
22. An isolated sixth nerve palsy in a patient older than 50 years is most often due to:
A. demyelinating disease
B. traumatic brain injury
C. microvascular ischemia
D. brain tumor
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22. An isolated sixth nerve palsy in a patient older than 50 years is most often due to:
A. demyelinating disease
B. traumatic brain injury
C. microvascular ischemia
D. brain tumor
23. An isolated sixth nerve palsy in an otherwise healthy 30 year old patient unlikely to be due to:
A. demyelinating disease
B. traumatic brain injury
C. microvascular ischemia
D. brain tumor
E. Post‐viral
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23. An isolated sixth nerve palsy in an otherwise healthy 30 year old patient unlikely to be due to:
A. demyelinating disease
B. traumatic brain injury
C. microvascular ischemia
D. brain tumor
E. Post‐viral
Sixth Nerve Palsy: Evaluation
• Age < 40: – Trauma?
• Blunt head trauma
• Medial wall fracture
– Post‐viral or post‐vaccination?
– Duane’s?
– Thyroid?
• If no predisposing factors, needs neuroimaging!
• Age > 40
– Vasculopath?
– R/o DM, HTN, hypercholesterolemia
• R/o Temporal arteritis
• Ask about history of malignancy,
– If so, then needs imaging!
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24. A 79‐year‐old woman presents with an acute onset of binocular horizontal diplopia and dizziness. Examination reveals a left head turn with an esotropia that is worse on left gaze. There is decreased corneal sensation and decreased blinking on the left. Where is a lesion suspected
A. Occipital cortex
B. Cavernous sinus
C. Cerebellopontine angle
D. Orbital apex
24. A 79‐year‐old woman presents with an acute onset of binocular horizontal diplopia and dizziness. Examination reveals a left head turn with an esotropia that is worse on left gaze. There is decreased corneal sensation and decreased blinking on the left. Where is a lesion suspected
A. Occipital cortex
B. Cavernous sinus
C. Cerebellopontine angle
D. Orbital apex
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25. A 59‐year‐old man complains of decreased vision immediately upon emerging from anesthesia following cardiac bypass surgery. On examination, the patient reports bare light perception vision OU. External examination, extraocular movements, pupillary reaction, and examination are all normal.
25. A 59‐year‐old man complains of decreased vision immediately upon emerging from anesthesia following cardiac bypass surgery. On examination, the patient reports bare light perception vision OU. External examination, extraocular movements, pupillaryreaction, and examination are all normal. Which of the following is the most likely cause of the visual loss
A. bilateral anterior ischemic optic neuropathy
B. bilateral occipital infarcts
C. functional or nonorganic visual loss
D. pituitary apoplexy
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25. A 59‐year‐old man complains of decreased vision immediately upon emerging from anesthesia following cardiac bypass surgery. On examination, the patient reports bare light perception vision OU. External examination, extraocular movements, pupillaryreaction, and examination are all normal. Which of the following is the most likely cause of the visual loss
A. bilateral anterior ischemic optic neuropathy
B. bilateral occipital infarcts
C. functional or nonorganic visual loss
D. pituitary apoplexy
26. What is the location of the lesion that causes a right homonymous hemianopic scotoma?
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26. What is the location of the lesion that causes a right homonymous hemianopic scotoma?
A. Posterior central chiasm
B. Left geniculate body
C. Left posterior occipital lobe
D. Junction of the optic nerve and left chiasm
26. What is the location of the lesion that causes a right homonymous hemianopic scotoma?
A. Posterior central chiasm
B. Left geniculate body
C. Left posterior occipital lobe
D. Junction of the optic nerve and left chiasm
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27. Following an automobile accident with head trauma, a young man complains of diplopia. In the primary position he has 6 prism diopters (PD) of right hypertropia. In left gaze he has 12 PD of right hypertropia. In right gaze he has 9 PD of left hypertropia. In primary position there are 15° of relative excyclotorsion and an esotropia develops in down gaze. What is the most likely diagnosis?
27. Following an automobile accident with head trauma, a young man complains of diplopia. In the primary position he has 6 prism diopters (PD) of right hypertropia. In left gaze he has 12 PD of right hypertropia. In right gaze he has 9 PD of left hypertropia. In primary position there are 15° of relative excyclotorsion and an esotropiadevelops in down gaze. What is the most likely diagnosis?
A. Bilateral fourth cranial nerve palsies
B. Right third and fourth cranial nerve palsies
C. Right orbital floor fracture with entrapment
D. Bilateral partial third cranial nerve palsies
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27. Following an automobile accident with head trauma, a young man complains of diplopia. In the primary position he has 6 prism diopters (PD) of right hypertropia. In left gaze he has 12 PD of right hypertropia. In right gaze he has 9 PD of left hypertropia. In primary position there are 15° of relative excyclotorsion and an esotropiadevelops in down gaze. What is the most likely diagnosis?
A. Bilateral fourth cranial nerve palsies
B. Right third and fourth cranial nerve palsies
C. Right orbital floor fracture with entrapment
D. Bilateral partial third cranial nerve palsies
28. Leber hereditary optic neuropathy is most commonly associated with
A. sex‐linked recessive transmission
B. a mitochondrial DNA mutation at the 3460 position
C. a pathognomonic optic nerve appearance
D. a mitochondrial DNA mutation at the 11778 position
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28. Leber hereditary optic neuropathy is most commonly associated with
A. sex‐linked recessive transmission
B. a mitochondrial DNA mutation at the 3460 position
C. a pathognomonic optic nerve appearance
D. a mitochondrial DNA mutation at the 11778 position
29. Which of the following is least consistent with toxic‐nutritional optic neuropathy?
A. A low serum and B12 and thiamine
B. A 1.2 log unit relative afferent pupillary defect (RAPD)
C. Temporal pallor of the optic discs
D. Bilateral cecocentral scotomas
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29. Which of the following is least consistent with toxic‐nutritional optic neuropathy?
A. A low serum and B12 and thiamine
B. A 1.2 log unit relative afferent pupillary defect (RAPD)
C. Temporal pallor of the optic discs
D. Bilateral cecocentral scotomas
30. A 26‐year‐old nurse in an ophthalmology clinic complains of right‐sided brow ache. Examination of both eyes is normal, except for the presence of a 1.5 mm, nonreactive right pupil to light or near stimuli. The pupil does not dilate in darkness. The left pupil is 4 mm and briskly reactive. The patient has no ptosis and normal ocular motility. The anterior chamber has no cell and flare. The most likely diagnosis is:
A. Instillation of miotic agent
B. Adie's pupil
C. Argyll Robertson pupil
D. Horner's syndrome
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30. A 26‐year‐old nurse in an ophthalmology clinic complains of right‐sided brow ache. Examination of both eyes is normal, except for the presence of a 1.5 mm, nonreactive right pupil to light or near stimuli. The pupil does not dilate in darkness. The left pupil is 4 mm and briskly reactive. The patient has no ptosis and normal ocular motility. The anterior chamber has no cell and flare. The most likely diagnosis is:
A. Instillation of miotic agent
B. Adie's pupil
C. Argyll Robertson pupil
D. Horner's syndrome
31. A 63‐year‐old right‐handed man has an isolated infarct of the entire left parietal lobe. Which of the following would you leastexpect to find on examination?
A. Right‐left confusion
B. Impaired optokinetic nystagmus with the tape going to the left
C. Acalculia
D. A right homonymous hemianopsia, worse in the superior hemifield than in the inferior hemifield
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31. A 63‐year‐old right‐handed man has an isolated infarct of the entire left parietal lobe. Which of the following would you leastexpect to find on examination?
A. Right‐left confusion
B. Impaired optokinetic nystagmus with the tape going to the left
C. Acalculia
D. A right homonymous hemianopsia, worse in the superior hemifield than in the inferior hemifield
32. A patient with sudden onset of severe headache, sixth nerve palsy, and a bitemporal visual field defect likely has
A. a ruptured ophthalmic artery aneurysm
B. pituitary apoplexy
C. meningeal carcinomatosis
D. multiple sclerosis
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32. A patient with sudden onset of severe headache, sixth nerve palsy, and a bitemporal visual field defect likely has
A. a ruptured ophthalmic artery aneurysm
B. pituitary apoplexy
C. meningeal carcinomatosis
D. multiple sclerosis
33. A healthy 50‐year‐old woman acutely develops a painful, postganglionic Horner syndrome. Imaging should be directed to find what pathology?
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33. A healthy 50‐year‐old woman acutely develops a painful, postganglionic Horner syndrome. Imaging should be directed to find what pathology?
A. brainstem stroke
B. apical lung tumor
C. carotid dissection
D. multiple sclerosis
33. A healthy 50‐year‐old woman acutely develops a painful, postganglionic Horner syndrome. Imaging should be directed to find what pathology?
A. brainstem stroke
B. apical lung tumor
C. carotid dissection
D. multiple sclerosis
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34. All of the following are features of tonic pupil except:
A. Tonic near response
B. poor light reflex
C. cholinergic denervation supersensitivity
D. Poor near reflex
34. All of the following are features of tonic pupil except:
A. Tonic near response
B. poor light reflex
C. cholinergic denervation supersensitivity
D. Poor near reflex
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35. Which of the following would be the best imaging study in a patient with a right optic neuropathy and third nerve palsy?
A. MRI of the brain with contrast
B. MRI of the brain and orbits with contrast and fat suppression
C. MRA of the head and neck
D. CT Brain and Orbits with contrast
35. Which of the following would be the best imaging study in a patient with a right optic neuropathy and third nerve palsy?
A. MRI of the brain with contrast
B. MRI of the brain and orbits with contrast and fat suppression
C. MRA of the head and neck
D. CT Brain and Orbits with contrast