Candidate 34                                        Centre: Bristol
MRCOphth                                                         Date: March, 2003


Case 1
Question: Examine this patient's anterior segments

Corneal dystrophy – macular, limbus to limbus and stromal, intervening areas are hazy. Graft in both eyes and contact lenses. There was also a tube in the left eye touching the corneal endothelium. Local area of oedema. No signs of rejection and all sutures were removed, AC deep. Other eye had recurrence on the graft. The recurrence looked to be both epithelial and stromal – mentioned this and examiner was seemed happy with the observation.

Followed by discussion on different dystrophies and then on recurrence. 
The indications for grafting.
Factors for graft failure
Why the tube was in the eye and what complications it can cause
How may it cause endothelial failure

Case 2
Question: Examine this patient's right eye with indirect ophthalmoscope.

Looked with indirect and found mild pigmentary changes in the macula but very subtle then examined the entire periphery. Panicked as I could not see any thing abnormal peripherally. Mentioned that I would like to indent as no abnormality was found. Examiner then agreed that periphery was normal. I was then asked to look at the macula with a 78D – cystoid macula oedema and very mild pigmentary changes.

What are the causes:
Mentioned all the usual ones including post operation and trauma
Also mentioned that there was no optic disc pit and no pars planitis with the indirect or foveomacular traction.
Eventually mentioned MEWDS and PIC and requested to see the other eye – wasn’t allowed
X-linked retinoschisis and Goldman Favre – examiner got interested to talk of retinoschisis and negative ERG’s and FFA and family history. Showed FFA – no leak at macula. I mentioned that this was a feature and ERG was better investigation. Asked for causes of negative ERGs

Case 3
Take a history from this woman

Woman 55 had “bleed” in the eye 2 years ago and also complained of visual obscurations lasting 30 mins. This was uniocular. On further questioning had visual auras like “shimmering lights”
Asked for headaches – no headaches
Asked for BP and DM and IHD and palpitations – history of BP and mild IHD and palpitations.
Bleeding in eye sounded like a vein occlusion

Examiner wanted to know what I thought of the problems were and what I would do in clinic. Mentioned that I would like to clarify the bleed – then told me it was BRVO and VA was 6/9. Mentioned that sounds like migraine but also due to PMH would like to examine carotids and CVS to exclude emboli.

Asked for features in history that would support either differential.
30 mins was too long for embolic disease and auras are not typical – more like migraine. But in view of history I said that carotids had to be examined. Examiner wanted to know if it was really necessary to scan carotids in this case – said yes it is cheap anyway. He left it at that.

(I later learnt that the same patient was used in the medicine and neurology exam for CVA examination and she had a carotid bruit which I was not allowed to examine)

Case 4
Question: Examine this girl's ocular motility Girl was 10 years old.

Patient had left over right in primary and the vertical deviation increased looking left. She also had no AHP initially but eventually had a head turn slight tilt to the left. On looking right she had some exo. Both elevation and depression in left gaze accentuated the vertical deviation. By now I was asked for differential. Was not sure so said that the IR in left eye or IO in right eye was underacting but that this was highly atypical cause of vertical deviations. Asked for history of myasthenia and previous surgery though I could not see any conjunctival scars or signs of trauma. Exmainers said to stick to IR and IO underactions. Mentioned I would like to do head tilt test thinking that tilt to right will worsen left IRUA and tilt to left will worsen IOUA. Turned out to be equivocal. Examiners asked what other test I would like to do and I mentioned Hess. They brought out a Hess – shows IRUA and SOOA (on other side).

Asked what sugery to do as kid having surgery in 2 months time. Mentioned kid was 10 and could do IR resection with adjustable sutures. Asked for another option – said SO tenotomy? Asked which was more appropriate – said the former. This was followed by discussion of pros and cons of each option. I was then asked to think of a reason the kid had exo on gaze right – I could not think of a reason but examiners did not push for an answer.

Case 5
Question: Look at macula of right eye. It is a spot diagnosis.
Straight forward CNVM with old discoform. Asked briefly about the classification and treatment options.

Medicine and neurology

Case 1
Question 1: Examine the fundus with direct ophthalmoscope.

The patient was an alcoholic.

Disc was pale in both eyes but more in the left than the right. He also smelt of alcohol and had nicotine stains on his hands. Was asked to examine his hands – nicotine stains no clubbing. I was asked what else I would like to examine neurologically and I mentioned his gait and also for peripheral neuropathy. 

Walking he appeared normal but Romberg’s was positive but did not have a stamping gait. Did not cooperate with testing sensation. Asked for other investigations, mentioned FBC, B12, folate , glucose LFTs and also offered a Hep screen. Brief decision on management.

Case 2
Take a history from this young patient

Young woman with loss of vision in left eye. Loss was gradual over past 6/12 and I asked for VA which was 6/12. This was worse than when she first noticed it. Went to optician no improvement – refraction was plano. No other neuro symptoms on history. No distortion. No PMH or FH relevant. Asked if lights appeared dimmer on the affected side patient was very definite that it did. At this point examiner asked if I were allowed to choose one examination which would it be = pupils = RAPD and also asked patient if torch appeared less bright in affected side = she was very definite it was. I asked to look in the eye and was instructed to do so with a direct. Left eye appeared hyperemic with obscuration of the edges temporally, right appeared normal.

Gave differential of optic nerve pathology, optic neuritis, optic nerve lesions and toxic causes, inherited causes which was unlikely in this case. Would this be compatible with optic neuritis? = no because the VA loss is gradual. How would you IX? – MRI or orbits and brain particularly orbits. Was then shown a MRI and also a CT (optic nerve calcification) = meningioma. Brief discussion on prognosis and management.

Case 3
Question:  examine the patient’s eye movements.

3rd nerve palsy with dilated pupil and also abberant regeneration. Lid retraction on downgaze and also on adduction. Patient had scar on the head – cause; fell down. Asked for causes of 3rd nerve palsies. Asked for investigations and this led to contraindications to MRI.

Case 4
Question: examine this patients fundus with 90D. Was told the VA was HM in left and NPL in right.

Patient could not shake my hand, hemiplegic.
Blind patient with wheel chair. Had bilateral burnt out DR with PRP and also grid and the fovea in one eye was lasered. Some tractional RD in right eye with no new vessels and did not involve the macular, no concurrent RRD. Optic nerves in both eyes look pale. Right eye had emboli at disc but could not see any in left. 

Asked for the cause of the poor VA – said likely embolic disease in right or optic nerve causes like ION. Was told he had left CRAO as well.
Asked for the indications of vitrectomy in DR.
Asked to examine lower limbs – had upgoing plantars and hyporelexia, and peripheral neuropathy asked for other causes of this.
Finally I mentioned would like to check BP and dipstick urine – asked about BP and  type 2 DM and brief discussion of UKPDS and EUCLID.

Case 5
Question: examine this patient's fundi with 90D

Again another diabetic with what I thought to be moderate NPDR. Grid in left eye and looks dry. No macula edema in right. Right had a cataract.

Asked about how I would manage the patient. Discussed removing cataract if significantly troubling before the macula gets involved. Examiner seemed satisfied.

Asked if patient needed PRP – I said no and was asked about ETDRS classifications of NPDR. Examiner said he thought the NPDR was close to approaching severe and asked if I would treat – offered to asses his control of glucose and if this was improving and if the eye has not worsened throughout his F/U  - monitor closely and treat only is worsening. If on the other hand rapidly worsening from following up then I would consider treating or if one eye had very bad VA and treating only good eye or impending dense cataract that may occlude vision and make treatment difficult. Seemed to accept this explanation. 

Instead proceed to ask about treatment of a patient that had collapsed with no pulse. 

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