Patient management 1
case of carotid dissection causing painful Horner. Asked about
investigation and treatment options
Gave a scenario of sudden painful left eye with ptosis, dilated pupil,
limited extraocular movement and reduced cornea reflex. MRI was
normal. Most likely a case of cavernous sinus thrombosis
Patient management 2
Macula hole. Discuss on diagnosis, classification, management.
Gave a scenario: 34 year old acute BOV 6/24 both eyes, optic disc
swelling and macula oedema, snowball and vitritis. Ask to give
differential diagnosis: infectious, sarcoid, vasculitis
What test to order. How to interpret blood test without normal value
Treatment options: steroid and steroid sparing agents such as
azathioprine, methotrexate. Also discuss on various biologics.
Health promotion / EBM
RCT on intermittent exotropia and new grading of intermittent
exotropia to guide surgical treatment (Newcastle grading).
how to best answer a clinical question: RCT
Laser safety issue. How to ensure facility is safe. How to make a
report if thereís patient safety incident due to laser.
Patient got CSR with VA 6/12. Other eye VA 6/12 due to amblyopia. A
taxi driver. FFA show leakage very near fovea. Discussed on issue
regarding DVLA and not qualified to drive. Treatment options to hasten
recovery such as PDT although self limiting. Not funded by NHS if this
is the case. Ask patient to pay for treatment or wait until it get
better or worse. (then qualify for NHS claim for PDT).
cornea consultant did PDT on him and vision deteriorate to 6/60. How
45 year old man with previous LE BRVO 4 years ago with VA 6/24
developed recent CRVO RE with VA 6/60. Counseled him regarding chances
of recovery. (Apart from explaining patient condition about his
diagnosis, prognosis, treatment option and possible complication, I
also mentioned to him the need to stop driving and inform DVLA. Also
to do VF for him to ascertain if he qualify to partial sight
impairment registration (CVI).
Inferotemporal retinal depigmented scar in a young lady assessed via
BIO. Looks like Cryotherapy scar. Discussed on possible causes:
notably treatment for RD.
scar with NVD. Differential diagnosis of PDR and OIS.
depigmented scars near the optic disc: temporal and inferior to optic
disc measuring about 1 disc diameter. Disc normal, macula normal.
Noted dot blot hemorrhages periphery. DDx Toxoplasmosis. Examiner lead
me to discussion of radiation retinopathy and its treatment.
Strabismus and orbit
Post recess and resect for 6th nerve palsy. Perform cover
and uncover test.
examination noted prominent lid lag in a middle age guy. Diplopia on
lateral right and left gaze but very minimal restriction. Patient was
quite obese. Flush face. Most likely hyperthyroid with TED. Although
absence of lid retraction, exopthalmous, lid swelling etc.
Axial Proptosis of the LE in young lady with abduction deficit. Asked
about most likely diagnosis. Iím not sure although I volunteered
thyroid eye disease and cavernous hemangioma as the likely cause. I
was asked what is the most likely tumor. Also mentioned possibility of
optic nerve sheath meningioma (although unlikely cause patient is a
young lady). Maybe it could be optic nerve glioma
old lady with nearly complete ophthalmoplegia except left eye 50%
abduction. No ptosis. Dollís eye negative. Not sure diagnosis.
Discussed on possible differential diagnosis of complete
ophthalmoplegia such as Miller fisher, CPEO, CFEOM.(I was later told
itís a case of perinaud syndrome)
Adult male LE acute partial ptosis for 2 weeks. Asked me to examine
the relevant thing. I was distracted and proceeded to do ptosis
examination with measurement! Prompted by examiner to stop and give a
likely impression: I said could be horner. Proceeded to check pupil
size in light and dark. No difference appreciated. Nevertheless,
proceeded to discuss investigation and management of horner syndrome.
Direct ophthalmoloscopy examination: noted pale disc with increased
cup disc ratio in both eyes. Examiner seemed content I only mentioned
Cornea and Anterior segment
Pseudophakic both eyes. RE with peripheral Iridotomy and irregular
small pupil. Discussed on causes of irregular small pupil in this
patient. (I am not sure but mentioned on possible trauma to pupil
during cataract surgery for small pupil. Thinking back, patient could
have had long term of pilocarpine due to narrow angle glaucoma).
Discussed on intraoperative management of small pupil.
Decompensated RE cornea, vascularized superior limbus. Iris attached
to the superior cornea from 10 to 2 oclock. Subluxed intraocular lens.
I mentioned diagnosis of pseudophakic bullous keratopathy. Perhaps it
was a case of traumatic cataract with poor zonular support. The other
eye looks normal with very early cataract. Forgot to check for
presence of Fuchís endothelial dystrophy in the contralateral eye but
examiner did not pursue this possibility. Discussed on management of
pseudophakic bullous k: conservative and surgical management which
include DSAEK or PK and scleral fixated IOL.
Primary acquire melanosis and a conjunctiva nevus. Discussed on the
type of PAM (typical vs atypical) and the need for biopsy and
Glaucoma and Lid
young man with bilateral ptosis and examiner gave a short history that
patient was seen at cataract pre op assessment. Did ptosis
examination. I was told EOM was normal. The medial canthus appear
slightly inverted and I volunteered blepharophimosis as diagnosis. I
mentioned CPEO and myotonic dystrophy as differential. I was prompted
how to check for myotonic dystrophy. I shook patient hand and noticed
he has difficulty to relax. Mentioned I like to check for Christmas
Asked to assess optic disc of both eyes with slit lamp. Noticed
increased cup disc ratio 0.7 with inferior and superior notching in
both eyes with right eye optic disc rim appeared paler than the left
eye. Disc size same, no disc hemorrhage, PPA. Unable to appreciate
RNFL loss with red free filter. I said patient probably have glaucoma
but need to rule out other possibility by doing CT/ MRI scan of orbit
and brain. Examiner not very happy asked me what other routine test I
would perform. Then I mentioned check IOP, VF, OCT. Was told IOP 40
both eyes. Then I corrected myself that I wouldnít scan him if IOP and
VF is consistent with the disc changes without other neurological
deficit. We also discussed on management of COAG: medical and