Candidate 49                                                Centre: Singapore
MRCS (Passed)                                                               Date: April, 2004
Clinical General Ophthalmology
I only saw 4 cases.

Case 1: Fuch's endothelial dystrophy.
Middle age man. Mild subepithelial corneal haziness with pigments on endothelium and stromal oedema. I mentioned there is no sign of previous acute angle closure glaucoma, PI or trabeculectomy scar. The examiner asked me to look at the cornea again carefully, and there WAS guttata!! Asked about how to tell stromal oedema from slit lamp exam.

Case 2:  Inferior and inferotemporal chorioretinal atrophy with dome shaped indentation.
Young woman. Fundi not myopic. Ask about ddx. My first guess was inferiotemporal retinoschisis with previous cryo ( thought this would be likely in exam setting esp it was inferotemporal). Examiner asked what is more common than retinoschisis. I said RD. He asked me what the domed shaped thing was. I said could be buckle. Ask me to look for it with bare eyes. I asked the patient to look medially and up and there it was.

Case 3: Alternating exotropia with V pattern in young boy
 Surprised to see this kind of case initially but they want me to demonstrate V pattern and tell them he will need muscle transposition if kin for surgery.

Case 4: Keratoconus
Ask to examine the red reflex with a direct ophthalmoscope. Saw oil drop sign. Ask to demo all signs including Rizzuti and Munson sign. Ask about management of keratoconus in general.

Clinical Neurology and General Medicine
I saw 8 cases.

Case 1: Elderly woman asked to perform VF. I asked her whether she can see whole of my face with either eye covered and she said yes. Patient is not co-operative and keep moving her eyes on confrontation. I then asked her to cover her eyes in turn again and ask her whether there is any part of my face missing and she said yes this time!! Her description was compatible with left homonymous hemianopia. The examiner then ask me since the patient is not too co-operative, what would I do next. I mention about wringling fingers for peripheral fields but I think he wants me to compare colour differences between red bottles. He then ask me to use a red pin. Since I have only 1 red pin, I then tried to map her blind spot and look for central scotoma. The examiner was not happy but he asked me to look at the disc.
I saw temporal pallor and I asked to see the other eye. Examiner said the other eye looks the same. He then asked me what I think. I said the VF is not rewarding but since the optic disc shows temporal pallor, I would think about chiasmal lesion. He then nod his head. 
I thought I have failed as this was my first case and it took me more than 5 minutes.

Case 2: Middle age man with left lid retraction and right partial ptosis with prominent lid crease. Ask to inspect. I confirmed proptosis by looking from behind and above. I then did the cornea light  reflex and it looks quite symmetrical. I proceed to EOM and there was some limitation on abduction and adduction for both eyes but he patient said he has no diplopia. I was asked about differential and I mentioned thyroid. I was asked why he has ptosis on one eye and lid retraction on the other. I mentioned the ptosis could be due to levator dehiscence. I was then led to another case.

Case 3: Middle age lady with burnt out PDR  with fibrosis along vascular arcades and laser marks at peripheral. I was then ask what stage of DMR is that. (examine with superfield lens)

Case 4: Young man told to have unilateral visual loss and pain. Asked to check VA. There was no letter charts in the room and his worse eye could see the picture on opposite way but he mentioned it was blurred. Can not test colour desaturation because there is no red target. I asked to perform pupils exam and there was L RAPD. I asked to see optic disc and there was optic atrophy. I was then asked about differential. I said MS. I was asked about management and Ix (MRI).

Case 5: Young man with unilateral visual loss after trauma. Told to exam VA. The left eye could see objects on opposite wall but could not read the letters from the tissue box (that was the only target available). I said I would like to exam his pupils. There was L RAPD and sluggish direct light response. The examiner ask me what I want to do and I mention to look at the optic disc and there was optic disc pallor. So it was a case of traumatic optic neuropathy.

Case 6: Ask to perform general inspection. The patient has Apert's syndrome with all the facial features and also syndactyly.

Case 7: Strange case. Middle age man. Ask to observe and then proceed. there was AXT on inspection. Confirmed with cover test. EOM showed limitation on adduction and ataxic nystagmus. However, on covering one eye, the adduction returns!! I mentioned about INO and would like to check other signs of MS such as cerebellar signs. The examiner then ask me what will I think it he tells me this case was like than since young. I couldn't think of anything else. I mention AXT with congenital nystagmus, knowing that this would not be the right answer. I don't know the real answer in the end.

Case 8: Told to inspect a young man. Saw a right exotropia. No ptosis. I ask to check for anisocoria. The examiner ask why. I said I want to rule out 3rd nerve palsy. Then the bell rang! Save by the bell...

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