Candidate 100                                            Centre: Bristol
Final MRCOphth                                                        Date: March, 2007


  • Conjunctival pingueculum.

  • MRI brain showing paraventricular plaques.

  • Lab results showing deranged liver function, diagnosis should be CA liver with choroidal metastasis.

  • Eyelid specimen with actinic keratosis?

  • Granular corneal dystrophy, questions on other stain for corneal dystrophy.

  • Conjunctival lymphoproliferation, with few slides of immunohistochemical staining for B- & T- cells.

  • Differentials. Types of ANCA.

  • Fungal keratitis with hyphea in corneal biopsy specimen.

  • Intraretinal CMV.

  • Chlamdyia with inclusion body.

  • Dermoid cyst.


Posterior Segment:

Case 1:

Patient with bilateral macular scars and satellite lesions in the periphery. Mention DDX as ARMD, myopic macular degeneration, posterior uveitis, POHS.... Asked in details of POHS, including where does it from, should be from Mississipi, not Middle East as I said.

Case 2:

Patient with RP fundus and pale disc. Ask for a differential diagnosis.

Case 3:

Ask to comment on an FFA picture of patient with parafoveal telangiectasia.

Case 4:

Ask to comment on an FFA picture of patient with a choroidal mass(?). The bell rang before I could say something.

Glaucoma Station:

Case 1:

Ask to exam patient's RE and talk about  positive findings. Can only see a dilated pupil with nuclear cataract and some AC cells. Then asked to exam LE, which shows a trabeculectomy bleb. Asked what to do if operate for cataract on eye with small pupil. What to do if RE has a failed bleb? Say would do a combined phaco+ trabeculectomy with MMC, or can consider drainage device.

Case 2:

Ask to comment on Humphrey VF which showed left incongruous homonymous hemianopia. Talk about various parameters.

Case 3:

Ask to comment on a Goldmann perimetry showed tunnel vision of only central 10 degree. Ask for possible causes, say RP, end-stage glaucoma, extensive PRP etc.

Case 4:

Ask to see a patient with enlarged CDR on both sides. Show the pachymeter machine and tell what is this? What is normal corneal thickness? What is the
IOP if corneal thickness is 500 microns in this patient, higher or lower?

Case 5:

Ask to calibrate the tonometer (like in Part 2)

Case 6:

Ask about the disposable tonometer tip. What organism could be transmitted by using the ordinary tip? Bell rang.

Communication Station:

Ask to get consent from a lady(should be an actress or staff as she read from a script) with senile ptosis to undergo levator reattachment under LA. Patient said she's scared. So offer sedation with LA, and said there is advantage to operate under LA as can make adjustment on table, etc. Also talk about other possible complications such as under-/over-correction, orbital haemorrhage etc.

Anterior Segment:

Case 1:

Patient with BE PKP. RE graft is oedematous. Thought there is an ACIOL in RE anterior chamber. But the examiner was quite surprise to hear I mentioned the presence of ACIOL, and one of the examiner go to take a second look on the patient! After that, he asked what did I think? I said pseudophakic bullous keratopathy, and he asked me about the management. Thought it should be something wrong with this case, as I could see the examiner started writing 'essays' on the marking sheet!!! 
Case 2:

An elderly patient with BE aphakia and PI, some vitreous strands in AC. Ask to exam the endothelium. Perform specular microscopy and found some corneal guttata. Say Fuch's dystrophy, but also mention could be age-related degeneration like Henle-Hassell bodies. The examiner asked can diet cause this condition? I said yes, then asked how? I said it can cause some abnormal deposition on endothelium. He then asked can surgery cause this? I said yes.            
Case 3:

A young girl with BE crystalline deposits in the anterior stroma, extend to the periperal cornea. Said could be Schnyder dystrophy, DDX include Biette dystropy, other mineral deposit or post-infection like streptococcal crystalline keratopathy, etc.

Case 4:

Ask to examine an old lady with some striae in the LE cornea. Bell rang before I can say anything.

Neuroophthalmogy Station:

Case 1:

Ask to observe an elderly man and tell what is abnormal(?) Then examiner asked the man to walk in the room, I said he has wide-based gait(?) The examiner then asked to exam patient's hand. On inspection there was resting tremor, and cogwheel rigidity on testing tone. Then said I would like to test for Parkinson associated ocular features, such as decreased gabella tap, impaired vertical gaze. Asked to examine ocular motility. Said I would start with cover and uncover test. Examiner seemed agitated and said do you think it's useful to do cover & uncover test in this patient? I stammered and said no and went straightly to test eye movement and saccades. He had impaired vertical saccade. Then I tested infranuclear supply by doing Doll's eye reflex. The examiner seemed happy with these and he asked what would I like to do? I said do a brain scan to look for pathology in the midbrain...         

Case 2:

Ask to examine pupil response in an old man. One of the examiner seemed agitated when I used my torch to elicit the light reflex. He even asked is this the right setting to do pupil test? I immediately said oh please dim down the light. He was still unhappy and came to grab the indirect ophthalmoscope on the ground to shine the light on the pupil. I was very scared by his action, but still said there was no direct, consensual and RAPD detected. He then asked me to examine patient's VF, which showed right homonymous hemianopia. Then I used a white pin to delineate the VF defect, which is congruous in nature. He then asked me where is the lesion, I said should cause by stroke in the left occipital lobe, and would like to test for macular sparing... Bell rang. I was really scared by this 2 examiners. Made me sweat a lot!!!

Medicine Station:

Case 1:

An old man present with painless sudden onset of LE decreased vision.Said DDX: CRAO/BRAO/AION/NAION. Asked to take history from patient. Patient said he had surgery on his heart valves, and taking digoxin. Asked to perform CVS exam. Heard a mechanical heart sound on 1st heart sound, and diastolic murmur. Asked which heart valve is abnormal? Said Mitral valve. Asked if patient on warfarin what should be checked? Said INR. Asked if INR now is 1.4? Said it's too low, should increase to 2 to 4.

Case 2:

An middle age lady with proptosed RE, went to A&E on Saturday night complaining of decreased VA. You're the house officer on duty, what should you do? Said I'll look for optic neuropathy related to TED. Asked to take history from patient for thyroid symptoms. Then asked to perform EOM testing. Then asked how to manage thyroid optic neuropathy. Said would give high dose methylprednisolone for medical decompression. Asked in detail the dosage (I think have given wrong numbers as later checked in the book!!). Then mentioned about surgical orbital decompression. Examiner finally asked what could you do if you are alone by yourself on Saturday night? I said oh I would like to perform a lateral cantholysis to relieve the intraorbital pressure! Bell rang.