Candidate 163


Centre:   Amman

   Date:    Oct 2011

My name is Khalid Ali Almubarek from Libya, I work in ophthalmology department- Misurata Central Hospital- Misurata- Libya. I passed ICO clinical exam in June - 2010 , part ii FRCS exam in Oct. 2011 and FRCS part iii in Amman -May 2012, by the grace of god I passed theses 3 exams from the first attempt, I dedicate my success to my parents and my wife for their support and prayers, I would like to thank my boss. Dr: Abdalla Musa, our head of department Dr Mohamed Swaisis, and my brother Dr Mohamed Bensasi for their support, also I would like to thank Prof Muthusamy Palanisamy, finally Prof C.N Chua for his amazing website.
Problem solving paper: Oct 2011:

Q1 - Young adult who previously underwent trabeculectomy for congenital glaucoma presented to you with high intraocular pressure
1- How would you manage him?.
2- What are the possible complications of your interventions?

1- Introduction: from the clinical picture given the patient is suffering from congenital glaucoma with failed trabeculectomy and I will consider another trabeculectomy augmented with antimetabolite. If failed I will consider tube shunt procedure.
2- History: I will ask the patient when was glaucoma first diagnosed, history of goniotomy?, traceculotomy?, previous and current medications? Time between diagnosis and surgery?, family history of glaucoma. I will check the previous records
3- Examinations: I will record the best corrected visual acuity, I will do slitlamp examination looking for the state of filtration bleb, the corneal clarity, epithelial or stromal oedema, descemet membrane folds, I will measrure the corneal diameter,I will measure the intraocular pressure, I will look to the depth of anterior chamber, iris for presence of peripheral iridotomy, and pupil for reaction to the light and accommodation, I will look to the lens for cataract?, I will do gonioscopy. I will do dilated fundus examination and look to the optic nerve head for degree of cupping?, atrophy?
I will do visual field and check the degree of field loss.
4- Investigation: CBC, , blood glaucose as part of routine investigation to prepare patient for surgery
5- Treatment: I will book the patient in the operation list for trabeculectomy, I will consider antimetabolit (eg: mitimycine to increase the success rate of the operation.
Complication of trabeculectomy:
1- Intraoperative complications:
- Conjuctival flap damage
- Sclera flap damage
- Bleeding
- Vitreous loss
2- Post operative :
- Shallow anterior chamber may caused by overfiltration, wound leak, papillary block, malignant glaucoma, or supra choroidal hemorrhage.
- High intraocular pressure: may caused by filtration failure, papillary block, malignant glaucoma or suprachoroidal hemorrhage.
- Hypotony
- Infectious endophthalmitis, blebitis.
- Failure of filtration.
- Complication of using antimetabolites ( corneal epithelial erosions, wound leak, infection, hypotony.

Q2 - 40 year old female came to you complaining of intermittent watering and discomfort of both eyes. How will you manage her?

Possible causes include:
1- tear hypersecretion secondary to ocular surface diseases ( blepharitis, conjunctivitis, keratitis, dry eye syndrome, trichiasis, entropion, thyroid ophthalmopathy )
2- tear outflow obstruction: ( punctum stenosis, abnormal lid position, canalicular obstruction, nasolacrimal duct obstruction)
3- I would like to exclude thyroid ophthalmopathy and Wegner granulomatosis
I will ask the patient about the onset, duration of the symptoms, associated ocular pain, deacreas in vision?, diplopia?,
Systemic review: any history of cough, shortness of breath, palpitation, abdominal pain, diarrhea?, heat intolerance? Night sweat?, weight loss? Neck swelling?,
Ocular :
I will check the visual acuity and refractive state of the eyes, color vision and pupil for light and near reflex, I will look for any evidence of proptosis,
I will examine the ocular motility
slitlamp examination ( I will look to the tear film, I will inspect the punctum and tha lid position, signs of blepharitis, I will examine the conjunctiva, and the cornea for signs of dry eye, I will stain the tear film with flourescein and inspect the cornea , I will do regurgitation test, dye disappearance test and I will do lacrimal syringing.
I will measure the IOP
I will examine the fundus
I will do confrontation test.

Systemic: I will check the vital signs ( pulse rate, blood pressure, respiratory rate, and temperature), I will auscultate the chest and heart sound.if I found any abnormality I will consult the internist for further evaluation
CBC, BLOOD SUGAR, urea & electrolytes, TFT,CANCA, chest XR, CT scan orbit and PNS,
If thyroid ophthalmopathy:
In mild cases I will advice the patient to elevate the head during sleep, cold compresses , and use of artificial tears. Refre to internist for systemic treatment.
In severe cases systemic steroid and immunosuppressant in collaboration with internist
If Wegner granulomatosis I will treat with systemic immunosuppressant eg: cyclophosphamide in collaboration with internist.
If ocular surface disease I will treat according to the cause

Q3 - 49year old female who recently noticed difference in her pupils size. How will you manage her?

Possible causes include:
- Physiologic anisocorea.
- Adie tonic pupil.
- Horner syndrome
- Drug indced.
- Trauma
- Uveitis.
I will ask her about the onset and duration of her symptoms, any associated ocular symptoms ( pain, decreased vision especially near vision, redness, photophobia, floaters, diplopia ), any history of trauma, recent medication in the eye,
Systemic review: any history of headach, nausea& vomiting, any neurologic deficit, neck swelling, couph, breathlessness,
I will measure the distant and near visual acuity, refraction, color vision
I will check ocular motility for any defect
I will assess the pupil reaction to light and near reflex
I will measure the pupil size in dim and bright light
If the difference in pupil size is equal in both bright and dim light then physiologic anisicorea is the most likely diagnosis.
If the difference is more obvious in bright light then the larger pupil is the abnormal one: possible causes include
- unilateral use of mydriatics
- traumatic mydriasis ( history of trauma, sphincter tear, iris dialysis on slitlamp examination
- adie tonic pupil ( large pupil with vermiform movement noticed on slitlamp, slowly react to light and accommodation, and show denervation hypersensitivity with weak miotic agent).
- Third nerve palsy ( other signs of motility defects, ptosis)
If the defference is more obvious in dim light then the smaller pupil is the abnormal one, possible causes include:
- Horner syndrome ( other signs include mild degree of ptosis, anhydrosis of the ipsilateral side of the face, central causes include CVA, multiple sclerosis , SOL, Pancaot's tumour, neck lesion , carotid dissection, cavernous sinus diseases) . I will do cocain test to confirm the diagnosis and hydroxyamphetamine test to differentiate 3dr order neuron lesion from first and second order neuron lesion.
- Unilateral use of miotic drugs
- Posterior synaechia
I will complete the slitlamp examination looking for the signs listed above
I will measure the IOP
I will examine the fundus looking for and retinal or optic disc abnormality
I will examine her old photograph and ask her husband if he noticed her problem
Systemic examination :
- full neurological assessment by neurologist
if horner syndrome is confirmed I will request MRI, MRA head and neck, CT scan chest
treatment: according to the cause

Q 4- 29 year old male who developed shortness of breath and wheezing shortly after he underwent flourescein angiography. How will you manage him?

According to clinical scenario given the patient has suffered a moderate to severe degree of anaphylaxis reaction following intravenous injection of fluorescein dye as he is in moderate distress . I will take following urgent steps

In a situation like this action takes precedence over history . However I will ask following points from attendant afterwards as diagnosis of anaphylaxis is clinical one in first instance.
1. Any history of previous allergy.
2. Did he had FFA before - similar reaction or more severe .
3. I will check previous record if available.
4. Any hospitalisation at that time.
5. Any history of atopy, drug allergy, food allergy-- allergy prone individual.
1. I will ask my assistant to help the patient to lie on a hard bed and raise his legs.
2. I will check her B.P., Pulse, Resiratory rate.
3. I will ascultate his chest and heart – wheeze & heart rate.
4. I will quickly examine him as in anaphylaxis there is multi system involvement (respiratoy, cardiovascular ,nervous system,eyes, skin, GIT.)
INVESTIGATIONS - I will request for CXR, Glucose ,FBC ,ABG, platelets and coagulation profile.—needed for management and assessing progress of case afterwards.
Differential Diagnosis
1. Anaphylaxis.
2. Hypoglycemia
3. Asthma attack
4. Vasovagal attack.
Final diagnosis
ACUTE ANAPHYLAXIS following I.V. Fluorescin injection
1. Oxygen 100% immediately.
2. Secure I.V. line
3. Inj. Adrenaline 0.5mg (0.5ml 1 in 1000 ) I.M. –mointor pulse , B.P. ,respiration. Repeat in 5 mts if no clinical improvement.
4. Salbutamol nebulized 100micro gm /puff.- to relieve bronchospasm.
5. Inj. Chlorphenamine 10mg i.v slowly.
6. Inj. Hydrocortisone 200mg i.v. slowly.
7. I.V. normal saline 500ml/20mts. titrate B.P.
8. I feel patient will be revived with above measures if not then help team should be on scene and take over the patient for further necessary management.

I will admit my patient for at least 48 hrs in emergency as some times anaphylaxis is biphasic means second crisis may be even more severe than first at presentation and can be life threatening. I will discharge the patient only after final clearance from internist and instruct him to stay near hospital for at least 48 hrs.
I will educate my patient about this allergic reaction - how to prevent it and to carry a card always with her mentioning this information about anaphylaxis. All this will make my patient satisfied.


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