Candidate 157

Part 2 FRCOphth

Centre:   Sheffield

   Date:    Nov 2011

FRCOphth 2 Sheffield 2011 (Passed)

Communication skills

The scenario was explain to a mother who’s child is being treated for a hypermetropic anisometropic convergent squint with glasses and now needs patching. She does not understand why the good eye needs to be patched and wants the child to have squint surgery. You have to explain why squint surgery is not an option at this stage.

I approached this by asking her to outline her concerns, and to explain what she understands by her child’s condition. From this it was evident that she did not understand that refractive correction is necessary to treat ambylopia. I resolved this by pretending to show mum with trial frames with the child’s refractive error to demonstrate how blurred the child’s vision is without glasses. She accepted this. I then explained how important a clear image is in the normal visual development of a child. If one eye has a clearer image than the other, then it is only natural for the child to want to only use that eye and for the other eye to become lazy. Therefore the first and most obvious step in treating this is with glasses. I then outlined how including patching helps to further promote more visual development in the lazy eye by essentially forcing the brain to use that eye and therefore develop the pathways on that side.

Mum responds that she understands that this is important but that it will be extremely difficult to get the child to cooperate with patching. She feels that is will upset the child.

I responded to this by stating that I would expect any child to be upset by patching. I understand how difficult and upsetting to force this on a child, but to bear in mind that the child does not understand why, but you do. You have to bear in mind that you are doing this for their future benefit and they will thank you later for your patience, especially if they decide they want to be in a career that requires good vision in both eyes such as a pilot. I also explained that patching can be broken up into smaller chunks and that there are methods in encouraging the child. I suggested decorating the patches, rewards charts and time with a play therapist to demonstrate. I also suggested some information leaflets.

I explained that squint surgery at this stage would not be recommended as it would be cosmetic in nature and would do nothing for the child’s vision. I explained that if ambylopia is adequately treated that the eye will begin to straighten. Squint surgery can be an option later on when they are older if this is not successful. I asked if there were any further questions, which there were none, and then suggested a follow up appointment to follow up on the patching regime.

Data Interpretation

This was a TED station. There were questions on the grading of TED- I gave Mourits and EUGOGO, and the expected questions on management which I based on EUGOGO guidelines- lubricants, selenium and immunosupression. There were CT interpretation- Enlarged muscles consistent with TED. Tendons not involved therefore distinguished from myositis. What are the advantages of CT and MRI imaging. I outlined time, noise, radiation different tissue modalities etc. When MRI useful in TED? STIR Sequence and in suspected Optic nerve compression. Had to interpret and MRI demonstrating TED with Optic Nerve Swelling. Then had to interpret a Hess chart showing bilateral lateral rectus underaction. Esodeviation of both eyes. Was asked to quantify- each box means 5’. Was asked how I would manage the double vision. I outlined occlusion, botox and finally strabismus surgery- when stable and decompression surgery complete.

Complex Case 1.

Trauma with globe rupture. Was asked how I would manage. Did the usual history examination. Imaging including x ray and CT orbits. Was shown an x ray then a CT demonstrating an IOFB. How would I proceed. I said primary repair with removal of IOFB at later date (It was in the vitreous) as VR cover not avaialble. Explained careful consent and prognosis. Outlined how I would approach the surgery- EUA, peritomy swinging up recti suture choices etc. Asked about primary enucleation. I stated that I would always aim for primary repair in the first instance even in the most severe cases to allow the patient to come to terms with the loss of the eye. Was asked about sympathetic ophthalmia. I said if wanted to avoid would need to do enucleation within 2 weeks.

Complex Case 2.

Scenario where you are asked by the medical team to review a 16 year old girl on ICU with a 6th nerve palsy. History of otitis media 1/12 ago. I outlined bedside VA assessment with hand held chart, Ishihara’s, pupil assessment, EOM, VF on confrontation. Ask if okay to dilate patient with medical team the examine optic nerves with direct/indirect ophthalmoscope. Was shown a picture of gross papilloedema and asked to describe and then outline what I would do next. I stated my differentials which included Gradenigo’s syndrome, SOL- and specifically cavernous sinus thrombosis. Outlined bloods and imaging and then supplementary tests when patient fit including formal GVF, orthoptic assessment and fundus photography, Was shown a GVF showing extremely restricted fields with enlarged blind spots. Went briefly into management which I said needed multi disciplinary approach as may need anti coagulation.

Attitudes, Ethics and Responsibilities.

Scenario was where consultant colleague has made a mistake in the management of one of his patients and wants to cover it up. How would you deal with this? I started with speaking to my colleague privately and attempting to outline in a non threatening manner his responsibilities in being open and transparent. An incident report needs to be filled in. I would need to ensure that the patient has come to no harm or that remedial action has been taken. I was then asked what my next step would be if he did not respond to this. I stated that I would have an ethical responsibility to report this and outlined the chain of command from line manager, clinical director, medical director, chief executive, royal college and GMC. I was also asked about safe site surgery and to give examples. I gave incorrect side being done during cataract surgery. I outlined WHO checklist. Then was asked to define probity- but ran out of time!

Also had a scenario where I as the consultant have performed a YAG capsulotomy on a patient who should have had a PRP- how would I deal with this. I took a 2 pronged approach to this- Firstly I need to remedy the situation at hand. The patient needs to be recalled an explanation given and apology and then the appropriate treatment, If he wishes to make a complaint then I would provide the appropriate complaints procedures to him. He would have every right to complain. The 2nd thing that needs to be done is measures to prevent this from happening again. An incident report needs to be completed and an investigation into why safeguards failed to prevent an incorrect procedure being performed. I outlined the traffic light system on the management of critical incidents.

Evidence Based Medicine.

The CATT study. Explain this study- I went through the non inferiority concept and study design. Was given the table comparing regular and monthly doses of lucentis and avastin. Was asked to interpret this. Explained that essentially avastin non inferior but not equivalent. Pointed out where the data was inconclusive ie when it could be inferior and non inferior at the same time. Was asked about which drug I would give my mother in law- I said lucentis. Can’t ignore the trend towards lucentis in the paper. Also cannot comment on safety as the study not powered for safety. Then was asked about teaching laser. I outlined laser safety rules, laser safety officer, laser safe rooms, googles etc.


Cornea and Lid

Case 1.

Bilateral Lower Lid Ectropion with Punctal Eversion and Stenosis. Asked for mechanisms of ectropion development- ie involutional, cicatricial etc. Was asked how to manage- I went for LTS with a medial spindle. Patient also needs punctal dilatation and syringing and probing- which requires a local anaesthetic.

Case 2.

Pseudophakic patient with a PI and a Trabeculectomy. Small amount of Anterior Chamber Activity. My differentials were previously treated ACG or a form of inflammatory glaucoma. Was asked how I would treat- outlined medical and finally augmented filtration sugery.

Case 3.

Aniridia combined with Congenital Glaucoma. Obvious Haab’s Striae, enlarged corneal diameters and aniridia. Management?- I said EUA making sure to check IOPS with ketamine anaesthesia.

Glaucoma and Anterior Segment


Case 1.

HSK- large vascularised corneal scar. Management- I divided into initial acute phase and then long term management. Topical Acyclovir treatment, topical steroid treatment and then consider long term prophylaxis with oral acyclovir if recurrent- quoting the herpes eye disease study.

Case 2.

 Cataract assessment- man pseudophakic right eye with pigmentary changes on endothelium. NS++ other eye. Pupils not dilated. Was asked whether he would dilate well. I said no- he probably had PXF? Was asked how to manage this- I went through using intracameral phenylephrine, iris hooks etc.

Case 3.

Prosthetic shell one eye, aniridia other eye with mild cataract. Asked to consider cataract surgery. i said was reluctant as aniridia pro inflammatory condition and likely to trigger glaucoma and or corneal decompensation. Was asked if I had to do what precautions I would take- dispersive viscoelastics, BSS+, minimum phaco power etc...

There was also a patient with a Peter’s anomaly. When asked how I would manage, I went for optimising refraction. Was asked what kind of refractive changes I would expect- I went for irregular astigmatism.

Medicine and Neurology

Case 1.

Examine a male patients lower limbs. He has a scaly rash- Psoriasis. Then had to look at hands and identified features of psoriatic arthritis- onycholysis, swollen joints etc. Was asked what other joints involved?- All others are. What are the ocular features-?I answered uveitis.

Case 2.

Examine pupils female patient. Asked lights to be turned down. Had an obvious afferent pupillary defect.Then asked to use direct to examine optic nerves. There was bilateral optic nerve pallor one side more than the other. Asked for differentials- optic neuritis, SOL, trauma, radiation, AION, NAION, toxic etc. Then asked how I would investigate- I outlined the blood tests and then imaging (MR with gadolinium).

Case 3.

Confrontational VF on female patient. Bitemporal hemianopia with a nasal defect on one side. Was asked differential- tumour compressing optic chiasm most likely pituitary adenoma. Was asked to explain why she had double vision. I did a cover test and EOM and identified an exotropia. Was asked to look at the glasses- which had a prism. Which way is the prism?- Base in. She has double vision because of hemi field slip/post fixation blindness. How would I manage?- Needs imaging preferably MRI with Gadolinium including the Pituitary. Needs input from endocrinology and possibly neuro surgery.

Case 4.

Slit lamp examination of fundi of male patient. Had pigmentary changes both maculae and also surrounding optic discs. Also noticed buried drusen. Was asked differentials- this was angioid streaks with previously treated membranes. Was asked associations of angioid streaks - gave the usual and how membranes would be treated. I said anti-vegf injections now, but also stated that PDT also very effective in the past.

Strabismus and Orbit

Case 1.

Take a history. Young man who suffered a signifiant head trauma and had resultant double vision. Had to do an exam. Pupils showed a fixed dilated left eye. Aberrant regeneration of third nerve obvious on EOM. How would I manage- suggested occlusion, prisms and botox if possible. When stable for at least 6 months can consider squint surgery- would need a transposition procedure.

Case 2.

Take a history. Female patient with red eyes which was treated with ibuprofen in eye casualty. Previous RD surgery on one eye (RE). Thyroidectomy for hyperthyroidism. Has double vision. Do an examination. I checked for proptosis by looking overhead but i couldn t be sure of proptosis on the RE. Asked to use exophthalmometer. Wasn’t necessary. There was restriction in upgaze of the right eye and a buckle was evident nasally. My differential included mechanical restriction or TED or combination of both. I suggested that confirming the cause then treating the cause is the most appropriate course of action. May need IR recession.

Posterior Segment

Case 1.

Slit lamp examination of young man who suffered blunt trauma. Had iatrogenic dilated eye, zonular dehiscence, mild cataract, cryo scars and finally a buckle. Was asked what kind of tear he would have had- I said dialysis, and he most likely had break ora occlusive buckling. Was asked what would be other signs of previous RD surgery- I said tobacco dust, presence of oil or a buckle. Was asked how I would manage the cataract. I went for an anterior segment approach bearing in mind that there is a high risk of a dropped nucleus- use iris hooks/ tension ring etc.

Case 2.

 Indirect examination of male patient. Normal eye right eye. Left eye no view due to cataract. Asked what I would do next- the answer was B scan. What are you expecting? Retinal Detachment.

Case 3.

Slit lamp examination of posterior pole. Macular hole with positive watzke allen sign. Was asked about types of macular hole- I outlined the 4 grades then aetiology. Was asked about prognosis and surgery. Said better outcomes with better pre op VA. Surgery more likely to be considered in younger patients with shorter duration of visual loss (less than a year) with high visual requirements.


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