Candidate 156

Part 2 FRCOphth

Centre:   Sheffield

   Date:    Nov 2011

Candidate Experience, FRCOphth Part 2 Sheffield OSCE/VIVA


Station 1: Patient Data and Interpretation


Two nice examiners, lead in scenario suggested Thyroid Ophthalmopathy. Suggested indirect CCF as differential. Asked how to grade severity  - suggested NOSPECS criteria. Asked about NOSPECS – stumbled a little!


How to work up – suggested blood ix for antibodies etc and TFTs, examiner asked about imaging – said yes CT/MRI to look for recti enlargement with tendon sparing – asked adv CT or MRI? Said in this case not much adv either way as mainly want to look for classic signs of TED, but adv MRI if inflammatory component to nerve suspected and wanted to image nerve. Shown one axial CT with enlarged recti – poor, poor picture, said looking for tendon sparing but as picture poor unable to commit – examiner smiled and concurred. Showed coronal T2 MRI – identified as such with gross recti enlargement.


Asked how to follow up diplopia? Said Hess and Lees, and also objective measurement in clinic with prism bar in primary position. Showed Hess with convergent squint of 15 PD in primary position.


How to manage squint? Said may need to decompress first before muscle surgery.


Station 2: Patient Management


Two nice examiners, lead in scenario (35 yr old woodcutter who felt something hit his left eye while cutting wooden fence) suggested likely open globe injury with retained IOFB/closed globe injury. Showed picture with complete hyphema, no clear evidence of penetrating injury. No clue as to condition of lens.

Here’s the difficult part – so many possible pathologies I wasn’t clear about what they wanted, so they asked me


What would you do? So general, I said – if in Casualty, ABC, rule out life threatening injury, assess eye, look for open globe injury as evidenced by boggy chemosis, positive siedel etc flat AC, will assess for and rule out ECH and IOFB. How? I mentioned Bscan, but risk of causing ECH and infection, I said CT. Radiologist says go fly a kite, its Friday night.

I finally got around to AP/Lateral Xray!!O_O  - showed me AP xray with radio-opaque FB in the left eye.


What to do?

Admit, NBM, systemic antibiotic prophylaxis for traumatic endoph – asked what drugs, said i.vfortum 1 g stat and vanco 500 mg stat. Alternative? Yes, intravitfortum 2.5mg/vanco 1mg at time of primary closure. – continued in same vein, they interrupted said ‘yes yes, all that’s done, patient’s in theatre.’ I said, clean, drape, wire speculum to avoid undue globe pressure, peritomy, explore for wound apex, interrupted again! ‘Yes yes, all done, what to do? If lens ruptured, what to do?’ I said ideally remove at time of primary closure, but if unable, close with antibiotic and steroid cover, and do secondary removal later.


‘What about IOFB? When to remove?’ I said high risk of traumatic endoph – needs removal within 2-3 days.



Station 3: Patient Management


Lets not talk about this one, shall we? Tanked here, tricky lead in scenario, 16 year old girl in ICU, history of chronic otitis media.


Like I said, not gonna talk about it!



Station 4: Attitudes, Ethics, Responsibilities.


Lead in scenario of you’re the consultant on call, done bilateral YAGS on a patient, and when patient about to leave, you realize you were supposed to PRP him instead!

What to do?


Tip: Read Good Medical Practice guidelines on, excellent notes there.

Said, will be honest and forthcoming with patient, apologetic. Explain likely long/short term outcomes. If want to file complaint, will put them in touch with patient liason personnel, and assure him complaint will not prejudice our care for him. Reschedule PRP whenever he’d like.  File Critical incident report.


Examiners seemed happy, asked about process of CI reporting. Mentioned part of risk analysis for clinical governance. Mentioned risk manager/CI review committee/CI analysis software/feedback to all personnel.


Asked about coding of adverse events. Mentioned red/amber/yellow and death/severe damage to property etc. Actually wanted in as pertaining to Ophthalmology! Mentioned wrong eye surgery/right eye wrong surgery/patient death on table/collapse etc.


Asked how to avoid – mentioned checking consent/checking eye in ot by two independent personnel, examiner asked have you heard of checklists? :P Said yes, usually done at patient receival at OT airlock between OT and Ward staff checking pt identity/surgery/eye


Second scenario – consultant colleague has adverse incident, and refuses to report, wants you to cover up O_O. Said of course not, will encourage him to report it himself as going over his head without trying to reason with him undermines relationship. He refuses – what to do?

Mentioned where I work, I’ll go to Head of service, then from there goes to hospital authorities. Asked if I know NHS chain of command, I said no, sir.


Asked what probity is, scratched my head a little till I got it, said to act with honesty and integrity. Asked examples of breaking of probity, mentioned doctoring of study results and not being forthcoming with patient with adverse event.



Station 5: Evidence Based Medicine and Health Promotion


Discussion of 1 year results from CATT study which was sent to us beforehand. All of us felt waste of time reading study, hardly any useful discussion on it, just asked us to summarize and short discussion of study power. In the end they asked me which drug I’d use to treat mom in law! Said of course Lucentis – licenced option/NICE recommended.


Discussion of squash and protective goggles! Asked why many players may not wear goggles? I said inadequate knowledge of potential for injury and potential severity of injury.


Asked protective measures whilst doing PRP – serious?

Said goggles. How bout on the part of the NHS trust? Prodded me a little – finally came up with closed room/antireflective surfaces/matte surfaces/windowless/warning signs on laser/doors etc etc.


The two examiners here were very nice though.


Communication: Counsel a young mother whose son has partially refractive accommodative eso who isn’t keen for patching or glasses and instead insists on surgery.

Aims of station: counsel about the importance of glasses/patching and why not right time for surgery.





Station 1: Ant Seg and Cataract


Patient 1:  ‘Please examine this patient’s eyes.’

Middle aged gentleman. RE pseudophakic with apparently stable PCIOL, both eyes not dilated. LE ACIOL, with PI and few other iris TI defects. Large corneal section. Absent PC – but explained couldn’t be sure because pupil not dilated. Looked for vitreous prolapse, none seen, no signs of anterior segment complications from vitreous prolapse but mentioned like to check IOP. Asked about why ACIOL, mentioned likely poor Ant capsular support, asked possible scenarios, said likely complicated phaco plus large PCR/zonular dialysis, asked about lens power, lower or higher if ACIOL


Patient 2: ‘Please examine this patient’s eyes.’

Middle aged gentleman. RE normal, phakic, LE deep AC and phacodonesis, missed deep AC compared to RE till prompted, said likely previous closed globe injury with angle recession – how to follow up? Said lifelong for IOP check, fields, fundoscopy for discs.


Patient 3:  ‘Please examine this patient’s eyes.’

Middle aged gentleman. Bilateral symblepharon at medial canthi.Mentioned symblepharon, asked what it was – mentioned adhesion between lid and globe, asked by examiner, specifically, which part of lid? I said palpebral conjunctiva. Asked to present, I said likely cicatricial conjunctivitis, causes? Mentioned OCP and SJS and some other secondary causes.

Asked to take short history to differentiate SJS and OCP, asked about maintenance meds to differentiate OCP and SJS and prodded by examiner to ask about mouth ulcers.


Station 2: Glaucoma and Lid



Patient 1: ‘Please examine this patient’s eyes.’


Elderly lady. Started with RE, absolutely nothing, was worried I missed something, switched to LE,  vascularised, diffusely elevated, non cystic bleb, unable to see posterior extent. Phakic, undilated pupil with likely laser PI at 9 o clock but quite near pupil margin. Very, very small hint of PS at 7 o clock, no KPS or cells in aqeous. Examiner asked me what’s going on, I mentioned bilateral AC deep, and no signs of previous AACG so my differentials were POAG but PI? Pointed to previous AACG/CACG. Also mentioned possibly previous iritis but couldn’t be sure. Examiners then asked me to examine disc – glaucomatous, 0.9 pale. Examiner asked, what if this patient had uveitic glaucoma and cataract and had an iop of 22-23? Had to take 5-10 secs to gather thoughts then said if she had significant cataract and iop of 22-23, I’d counsel her for repeat combined surgery with augmented trab/GDD after inflammation well controlled and they seemed happy.



Patient 2: ‘Please examine this patient’s eyes.’

Middle aged gentleman. Took 5 seconds to inspect, large corneas with LE haziness. Huge haabstriae in the RE.Beware the Scheieprocedure!!!It WILL come up in exams!  Saw it at 12 o clock with some uvealprolapse, patient had partial Aniridia and high PAS visible at 7-9 o clock, phakic. Mentioned was looking for goniotomy or trabeculotomy scars, and  at first mentioned trab, but because of aniridia couldn’t be sure if PI patent. Examiner asked me to look again, this time committed to Scheie, examiner seemed pleased, said ‘ Possibly, possibly, no way of knowing for sure.’ Asked me what to do if the patient came as an 18 month old baby to clinic, and how would he present – mentioned eye rubbing, photophobia and lacrimation. Asked me how I’d check pressure, stupidly I said tonopen, they asked, have you ever tried checking iop with tonopen on 18 month old, I quickly caught on and said I’d EUA with ketamine induction and luckily they smiled.



Patient 3: ‘Please examine this patient’s eyes. He came with a history of persistent epiphora RE.’


Middle aged gentleman. Inspected, quickly noted significant lower lid ectropion RE. LE seemed ok. Examined on slit lamp. Keratinisation of both lower lid margins with obliteration of puncta. Looked for associated cicatricial changes, only when inspected more closely noted patient had rosacea. No corneal changes though. Got stuck when asking how to manage. Said control underlying disorder with avoidance of spicy foods to avoid flushing, oral tetracyclines. Said shortening procedure for right lower lid such as wedge excision, plus punctal snip procedure for punctal obliteration. Asked if wedge excision best method to correct ectropion? In hindsight should have said, graft? Prodded and said will also like to  probe and irrigate, time up – not too good.




Station 3: Posterior Segment


Patient 1:  ‘Please examine this patient’s eyes.’


Slit lamp exam.

Bilateral posterior polar very very heavy pigmentary changes with retinal/rpe atrophy and unmasking of large choroidalvessels..changes extended to mid periphery with sparing of far peripheries. Pupils only mid dilated so field of view not great even with my superfield 90. Vascular attenuation and pale discs but didn’t commit to waxy pallor.

Examiners asked me what I thought, I said first thought RP due to bilaterality of condition and vascular attenuation plus pale discs, but said atypical because far peripheries spared whilst maculas heavily involved. Asked what differentials? Mentioned hydroxychloroquine end stage retinopathy, phenothiazine retinopathy and carcinoma/melanoma associated retinopathy. Asked if it could be PRP? I said frankly I’d never seen PRP give rise to such heavy pigmentation, plus pigmentary changes appeared bony spicule-like. They seemed happy, and asked if patient was diabetic, was the diabetic eye disease active? Since the far peripheries were normal, I said no. Asked what changes I’d look for, said, h’ghes, venous segmentation, NV, VH etc. Examiners happy.



Patient 2: ‘Please examine this patient’s eyes, he had severe LE trauma many years ago.’


Indirect exam. Middle aged gentleman.

Fiddled a little with the indirect scope, terrible quality. But took my time, think it helps give confidence to examiners that you know your stuff if you’re not rushed and panicky. Examined LE first, phakic but no view of fundus due to cataract. Mentioned to examiner and she said yes, cataract there. Told me to examine RE. Looked normal to me, pseudophakic. Pink disc, 0.3, flat macula. Asked me possible posterior seg manifestations of ocular trauma. Mentioned whole list with RD and SCH top. Asked how I’d examine LE in clinic? I said Bscan. She smiled and said yes. That was all!


Patient 3: ‘Please examine this patient’s eyes, he had severe LE trauma many years ago.’

Slit lamp. Middle aged gentleman. Poor exam here. Straightaway noted pre equatorialencirclagebuckle at 3-5 o clock. Said Radial plomb SMH! Was told off by examiner why did you say radial when its clearly circumferential non encirclage? Was off my game after that, extremely dilated pupil, phakic, mild nuclear sclerosis, no phacodonesis, and very hypopigmentedfundus with large break 3-5 o clock anterior to equator corresponding to buckle, couldn’t see indent but mentioned. Mentioned fundushypopigmentation reminded me of albinism but didn’t see other signs, examiners appeared annoyed and said what else can you see? We mentioned he had severe trauma.’ Now in hindsight hypopigmentation must have been due to previous RD SMH.



Station 4: Strabismus and Orbit


Was dreading this station, but it turned out to be okay.


Patient 1: ‘Please take a short history from this patient. He has been having problems with his eyes for a while.’


Took history while inspecting patient. Young – middle aged man with left sided mild ptosis and dilated pupil. Had traumatic injury 15 years ago and has had diplopia since then. Asked him about diplopia in primary gaze, none. Asked about diplopia in which gaze positions? Mentioned in upgaze, downgaze, face turn.

Examined motility, beautiful 3rd nerve palsy with pseudo von graefe and pupil constriction in downgaze. Discussion on 3rd nerve palsy and reasons for aberrance, and natural progression of 3rd nerve as well as surgical options.



Patient 2: ‘Please take a short history from this patient who has been having some eye problems.’


Middle aged lady. Took history while inspecting, history was she had RD repairs in RE twice, with subsequent inflammation and was on oral meds for a while. Also history of thyroidectomy. Mentioned has diplopia now, I asked at what distance? Can she read without diplopia? Can she catch the bus? She said yes, only diplopia at 2-3 m, while watching telly.

Examined motility, limited upgaze RE which didn’t increase with ductions. Did saccades which showed sudden stop. Was staring for around half a minute before I rechecked – it was a Browns! Good thing examiner wasn’t annoyed. He then asked how to manage, I said I’d manage conservatively with prisms considering her diplopia was absent in primary position at near and distance and only present while watching telly. and examiner seemed happy.


Station 5 and 6: Medicine and Neurology



Patient 1: ‘Please inspect this patient and proceed.’


Gentleman in his 30s.Large RE esotropia in primary position with diplopia. Quick cover uncover test at distance shows slow refixationof  RE with clear preference for LE. Did motility, bilateral abduction limitation with poor improvement with ductions. Noted gaze evoked nystagmus in lateral gaze and vertical gaze. Presented my findings as initially right sided 6th nerve palsy, prodded and mentioned that LE 6th nerve also likely involved. Asked why GEN present, I said likely cerebellar dysfunction. Asked about cause, I mentioned since symmetrical all positions likely something widespread e.g hypnotics/anticonvulsant/depressant use. Asked to examine cerebellar signs – funny as no signs of rebound phenomena/dysmetria/intention tremor or dysdiadochokinesia. Examiner asked, ‘are you sure?’ but after examined for dysdiadochokinesia seemed like he agreed that no apparent cerebellar limb signs present. – asked me to put it all together, said couldn’t.



Patient 2: ‘Please take a history from this gentleman and proceed to examine.’


Elderly gentleman who had atherosclerotic risk factors and said his optometrist told him his ‘side vision’ was becoming poor. Difficult confrontation test as I think his peripheral fields were only very slightly impaired. Compared the fields with my mydriacyl bottles and came up with a left superior quadrantanopic defect. Examiner seemed ok and asked me to inspect the patient and asked me what I saw. Missed a transfrontal scar! which extended along the right frontoparietal suture. Asked me to then ask targeted questions and patient said he had an aneurysm prior. Funny, because I thought aneurysms bled into SA space rather than cause strokes which would usually be thromboembolic?



Patient 3: ‘Please examine this lady and proceed.’


Lady with myopathicfacies and bilateral ptosis.Eyes straight in primary position, cover/uncover normal. Motility showed full pursuits and no fatiguability/cogans twitch. Saccadic slowing. Examiner asked me to check weakness of obicularisoculi.



Patient 4: ‘Please take a history from this patient with uveitis and proceed.’


Gentleman with history of alternating acute uveitis currently off medication with history of chronic back pain and buttock pain with severely reduced cervical movement. Came up with ankylosingspondylitis. Time up, asked quickly about targeted examination and came up with HLA b27 and sacroiliac xray. Examiner seemed pleased.


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