Candidate 53                                                        Centre: Liverpool
MRCOphth (Liverpool)                                                            Date: September, 04

1. communiation station:

  • young nurse working in ICU with first onset of homonymous photopsias. related to migranous type symptoms.
  • first half of station for 7 minutes - asked to take history - exclude other causes of flashes, then tried to subtype the headache. asked for precipitating causes, history to suggestive more sinister causes of headache, social history, family history, medication history and past medical history.
  • was then asked by the examiners to summarise my findings, and give appropriate list of differentials.
  • examiners then told me examination was entirely normal and consistent with my top differential of migranous headaches.
  • second half of station for 6 minutes - asked to counsel the patient. told her about symptoms to watch out for, when to come back. how to manage and avoid headaches, counselling about driving, and most importantly asked her what she was most concerned about!
2. posterior segment station:
a. retinitis pigmentosa again - comment on fundus, vessels, disc wtih atrophic macula. Asked to comment on what i thought the visual fields were like, and what i expected the visual acuity to be.
asked on how i would define the UK standards for visual disability
how to counsel the family for genetic screening, manage patient (treat causes of reversible visual impairment) etc.
asked about inheritance patterns - as well as characteristics of AD / AR inheritance.

b. congenital optic disc pits - took me awhile to catch on, as i was quite sure that the appearance was that of an acquired pit with very severe notching of the disc. no posterior pole RPE attenuation, and i was told that the vision was 6/60. I could'nt explain it, and said that she did'nt have the appearnace of subretinal scarring / RPE attenuation that would account for it. THought i had bombed this one.

3. Glaucoma - 
a. very narrow angles with PI - asked how to assess depth. asked how to manage acute angle closure.
b. asked to examine posterior segment FIRST - brvo wtih collateral vessels and disc notching - told them that it was likely due to acute episode of raised IOP, leading to BRVO with collaterals, and rim notching secondary to RNFL loss. Was then instructed to examine the anterior segment, where noticed the functioning trabeculectomy bleb, iris atrophy but no cataract.
4. Medicine in relation to Ophthalmology
a. shown mild NPDR on direct ophthalmoscope.
asked by physician about further examination that i would like to perform, as well as tests i would like to do.Asked about the systemic manifestations of DM.
Asked about WHO diagnosis for DM and oral glucose testing.
Then asked to examine his lower limbs - demonstrated diabetic dermopathy, impaired vibration sense, and LMN signs of hyporeflexia. Otherwise nromal examination.
Asked about medical management of associated vascular risk factors
Asked about pharmacological Rx of hyperlipidemia, and medications used to treat. Asked about side-effects of statin medications.
b. shown lady and asked to comment on general appearance. Commented on mild blepharitis and thinned sclera. Missed any hand signs! (in retrospect, they were quite subtle, so did'nt want to commit myself). Was then asked to examine at slit-lamp.
Patient had scleromalacia perforans, significant anterior segment inflammation with posterior synechiae, and pseudophakia ou.
Asked about RA workup, and drugs used to treat RA. Asked about significance of RF.
5. Anterior segment
a. shown a young girl with posterior embryotoxon, corneal farinata (i think), and superior corneal scar. 
I told them differentials probably contact lens use, and that i would like to take a contact lens history etc., other signs of overwear.
asked about management, risk factors for ulcers etc.
b. other case was that of ou pseudophakia,very mild band keratopathy, pCO with YAG previously. Asked about the causes of band K.
6. Ophthalmology in relation to Neurology
a. told to examine EOM in lady with left acoustic neuroma excised. patient had lagophthalmos and exposure keratopahty (probably neurotorphic related). She had left gaze palsy - related to PPRF lesions. Did not pick up her ocular dysmetria until the examiner had to repeat saccades).
b. pupils - physiological anisocoria. Asked about physical signs, and pharmacological testing on how to differentiate anisocorias.



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