Candidate five Centre: LiverpoolDate: Sept. 1999Ophthalmology
The first patient was an 84 year-old woman.
I was asked to examine her fundi with a 90D lens on a slit-lamp. She had an old right branch retinal vein occlusion and a left epiretinal membrane in the macula with some hard exudate superiorly. The first examiner asked about the management of a branch retinal vein occlusion and the indication for laser. The second examiner asked me the differential diagnosis of epiretinal membrane and the most likely cause in this patient. It turned out that the patient had an old left macroaneurysm which had now become thrombosed but left behind some hard exudate.
Anterior segment examination of a young man.
The right cornea showed prominent nerves in the stroma but otherwise nothing of note. There was a left corneal graft without evidence of rejection and all the sutures were intact. There was no clue on the recipient cornea. I returned to the right cornea looking for signs of keratoconus but there was none. I mentioned to the examiner that I would like to perform corneal topography on the good eye for any subtle keratoconic changes. I was told that the patient did have keratoconus with prominent corneal nerves being the only sign in the good eyes.
Indirect ophthalmoscopy with a 20D lens on a middle-aged man.
There was a shallow peripheral retinal detachment in the right infero-temporal quadrant with water mark. There was also multiple holes on the inner retina. I made a diagnosis of retinal detachment caused by retinoschisis. I asked to examine the other eye and the patient had retinoschisis in the left infero-temporal quadrant without detachment.
The last patient was a middle-aged man.
I was asked to look at him and decide what examination I would like to perform. I noted that he had a left exotropia. I opted to examine his ocular motility and he appeared to have a blind left eye. The examiner then asked me what other signs had I noticed. It was not until one of the examiners putting his head next to the patient that I realized I missed bilateral bulphthalmos! The patient had bilateral congenital glaucoma. On the slit-lamp, he had signs of Haab's striae and scar from goniotomy.
Medical ophthalmology and neurology
Ocular motility examination.
The patient was a middle-aged man with bilateral ptosis. There was a restricted symmetrical ocular movement limitation. The patient also had poor facial muscle tone. I made the diagnosis of mitochondrial myopathy.
I asked to examine his fundi but there was no evidence of peripheral pigmentary changes.
This is a case of spot diagnosis.
The patient had bilateral blue sclera - a straight forward case of osteogenesis imperfecta. I was about the possible ocular and systemic physical signs related to this condition.
Direct ophthalmoscopy of both fundi.
The patients had bilateral central retinal vein occlusion with bilateral collaterals and hard exudates in the macula. I was asked about the physical differences between collaterals and optic disc neovascularization.
Slit-lamp examination of a patient.
I noted the presence of heterochromia (with the right eye being lighter) before the patient put her chin on the slit-lamp. The patient had all the classical signs of Fuch's heterochromic cyclitis ie. evenly distributed keratic precipitates, iris atrophy and posterior subcapsular cataract. I was asked about the management of Fuch's heterochormic cyclitis and the differential diagnosis of heterochromia.
The last patient was a young man. I was asked to examine the ocular motility.
The eye movement appeared normal until I performed the horizontal saccades. He had a mild left internuclear ophthalmoplegia.
I asked to test his cerebellar functions. He had a slight disdianochokinesia.
Lower limbs examination showed hyper-reflexia with upgoing plantar.
The patient had multiple sclerosis
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