Candidate 195

 

FRCOphth

Centre: Swansea

 

Date:   Jan 2015

 

Viva

Patient management 1

         A 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.

 

Investigation

         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 (you canít)

         Treatment options: steroid and steroid sparing agents such as azathioprine, methotrexate. Also discuss on various biologics.

 

Health promotion / EBM

         new RCT on intermittent exotropia and new grading of intermittent exotropia to guide surgical treatment (Newcastle grading).

         Ask 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.

 

Ethics 

         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).

         A cornea consultant did PDT on him and vision deteriorate to 6/60. How to proceed.

Communication

A 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).

 

OSCE

Posterior Segment

         Inferotemporal retinal depigmented scar in a young lady assessed via BIO. Looks like Cryotherapy scar. Discussed on possible causes: notably treatment for RD.

         PRP scar with NVD. Differential diagnosis of PDR and OIS.

         2 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.

         EOM 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

 

Neuroophthalmology

         An 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 glaucoma.

 

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.

         RE Primary acquire melanosis and a conjunctiva nevus. Discussed on the type of PAM (typical vs atypical) and the need for biopsy and subsequent management.

 

Glaucoma and Lid

         A 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 tree cataract.

         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 surgical.

         I canít remember.

 

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