|Constructed Response Paper
Describe histological slide: FW rosettes and fleurettes
4 possible differential diagnosis for retinoblastoma i.e. leukocoria
Tumour suppressor gene and its role in retinoblastoma
(2) Choroidal melanoma
(It might have been choroidal haemangioma)
Describe pathological specimen and histological slide (low magnification)
What other cells would you see i.e. on high magnification
(3) Giant cell arteritis
Describe histological features i.e. slide of blood vessel shown
Why could it still be GCA even if the biopsy is negative?
3 ocular complications
2 non ocular complications
(4) Prion diseases
What is a prion?
How do prions cause disease?
Name 3 prion diseases
How would you prevent the risk of prion diseases in ophthalmology?
A case scenario of a young keratoconic patient awaiting corneal grafting
and he is concerned about this risk. How would you counsel him?
What is the clinicopathological classification?
Wegener’s and role of ANCA
Describe histological slide
Complications of Wegener’s
(6) Pleomorphic adenoma
Describe histological slide
Malignant lacrimal gland tumours
Patient presents “2 days” following phaco with endophthalmitis
Name 2 most likely organisms
Name most important procedure for diagnosis
What 4 culture media would you request for culture?
2 advantages of vitrectomy
Another patient has a penetrating trauma related endophthalmitis.
Name 4 likely Gram -ve organisms.
Describe the picture: Agar plate showing colonies. 4 circular pieces
of paper impregnated with antibiotics, only sensitive to vancomycin.
What is the organism?
Management of MRSA patient on the ward
Name 2 routine stains used (not calcofluor white)
In what forms do acanthamoeba exist?
Name 2 treatment used
What culture medium would you use for fungal keratitis?
(10) Conjuntival slides
Rather odd looking, supposedly according to the caption there is elastotic
3 possible causes for this picture
How would you differentiate them clinically and histologically?
(11) Ocular cicatricial pemphigoid
Describe immunofluorescence slides
Name one linear IgG disease with systemic manifestations
Stevens Johnson: What are the immunological mechanisms and histopathological
Histological slide of retina showing all the layers. Mark on the
drawing where you would expect the pathology to be:
Cotton wool spots
(13) Phacolytic glaucoma
Describe slide of drainage angle
Mechanism of raised IOP
Name 4 ocular tissues affected by high IOP
(14) Optic neuritis
Visual prognosis in optic neuritis
What is the risk of MS?
What are the histopathological features of MS?
(15) Giant papillary conjunctivitis
Anterior segment disorders
Middle aged man. Patient had normal looking right anterior segment.
He had several vertical descemet’s breaks in his left eye and said perhaps
slight corneal oedema nasally. There was also a prominent conjunctival
cyst at the temporal limbus. I said I thought the cornea was enlarged
in diameter. I measured it and said about 12mm. I think I did
myself a slight disfavour here. Examiner asked to measure right cornea
and it was of the same diameter, retracted and said cornea was not enlarged.
Said possible trauma, unlikely congenital glaucoma. Seemed to expect
more, said can also result from surgical trauma i.e. descemet’s scroll
but no evidence to support previous anterior segment surgery. I don’t
know whether that was right in the context.
Classical case of OCP. Management and complications fully discussed.
Late middle aged lady. On general examination, noted right lateral
tarsorrhaphy and enophthalmos. She had a bandage contact lens, phthisical
eye with band keratopathy, shallow AC, disorganised anterior segment and
dense cataract. She was pseudophakic in the left eye, ECCE scar to
me and otherwise normal. Asked about reason for BCL, mentioned band
keratopathy and comfort.
Ocular motility and neuroopthalmology
Asked to assess ocular motility. Middle aged male patient with
a complete right ptosis, dilated pupil and proptosis. Asked examiner
for VA and he told me to check the right eye only, VA in left eye being
normal. His right VA was HM. The right eye would not budge
at all. Said patient had a total external ophthalmoplegia.
Mentioned that pathology was either orbital apex or cavernous sinus.
I would like to check his fundus. What would you do next? Neuro-imaging
is needed, I would request MRI scan.
Young lady probably in her 30’s. Asked to examined both optic
discs with slit lamp. She had bilateral temporal disc pallor.
Asked about differential. Mentioned demyelination and then because
of her young age, possible hereditary optic nerve disorders such as dominant
optic atrophy. How would you decide if it was hereditary? I
would ask about family history and then patient mentioned that both her
mother and sister are affected, more severely than her. I mentioned
that hereditary causes i.e. DOA was likely. Asked about features
Middle aged lady. Asked to only do ocular movement, no need for
cover testing. This lady had a right gaze palsy, no nystagmus.
Examiner seemed to agree, what else would you do? Mentioned saccades
and demonstrated abnormal saccadic movements to the right, normal to the
left. Asked where I thought the problem could be, said right PPRF.
Then rather obscure question about causes of “slowed” saccades. Mentioned
myasthenia but he did not seem convinced. Mentioned Parkinson’s disease
and progressive supranuclear palsy and he seems to be satisfied.
Ophthalmology and medicine
Asked to take history from middle aged lady, you could see that there
was sectoral conjunctival injection in both eyes. 35 year history
of recurrent red, photophobic eyes, normally only eye affected at a time.
Flare up about 2 days ago, now on steroids drops and atropine. Was
once admitted in the past for oral steroids. History of osteoarthritis
and she mentioned that her sacroiliac joints were “damaged”. She
also mentioned mild psoriasis. Son had ankylosing spondylitis.
She denied any skin or other systemic complaints. Interruped by examiner.
Asked to examine patient. She had mild conjunctival injection in
both eyes. She had no cells in her right AC, but some few cells floating
in the left eye. Right pupil was distorted with posterior synechiae.
She was pseudophakic in her left eye. Asked to link things together.
Mentioned possible HLA-B27 anterior uveitis (AS + Psoriasis), active in
both eyes. Possible early cataract in her left eye secondary to uveitis
and/or steroids use. Asked about whether I would investigate this
lady and what would I request? Mentioned that most uveitis do not
have to be investigated. Said HLA-B27 because it does predict recurrence
rate and need for early aggressive treatment. Asked about anything
else. Mentioned that it did not look granulomatous and he agreed
on that. Then slight mental block, not too sure whether he expected
more from me.
Middle aged lady. Asked to do fundoscopy. This lady had
cortical lens opacities in her right eye and was pseudophakic in her left
eye. Bilateral PRP, no NVD or maculopathy. Asked general questions
about diabetes control i.e. HbA1c and what other end organ damage that
needs to be looked into. Asked about factors that worsen diabetic
retinopathy i.e. poor glycaemic control, nephropathy, hypertension and
pregnancy are what I volunteered. Asked to measure this lady blood
pressure. Finished measuring systolic when bell rang.
Posterior segment disorders
Indirect with 20D, left eye only. Pseudophakic, 360 chorioretinal
scarring, optic disc normal, white choroidal scar in nasal posterior pole,
macula looked ok. Asked to venture a diagnosis. Mentioned likely
VR procedure and 360 laser scars. Told not laser what else?
Said likely cryo. Mentioned that white choroidal scar likely site
of drainage retinotomy.
90D slit lamp. Elderly lady with a choroidal naevus. Asked
90D slit lamp. Late middle aged man with a left elevated pigment
lesion with surrounding SRF involving half of the macula and the superior
retina outside the arcade. Surface drusen but no lipofuscin.
Asked about differentials and investigation. Showed A+B scan, possibly
choroidal haemangioma. Examiner seemed satisfied and then told me
that the diagnosis was actually unclear.
Glaucoma, cataract and visual fields
Examine anterior segment both eyes. Right anterior segment was
normal. Left eye, I thought there was a scleral flap visible and
small but functioning looking bleb. Patient was pseudophakic in left
eye. Interrupted by examiner, what is missing if he has had a trabeculectomy
as you just said? Checked again thinking I missed a peripheral iridectomy
but I could not see none. Said that it might only be a scleral tunnel
for cataract surgery after all. He then asked me about what other
types of drainage surgery it could be. Then something clicked and
I mentioned possible non penetrating surgery. Asked what types I
knew of, somewhat hesitantly said viscocanalostomy and deep sclerectomy,
because I was not sure how to spell them out.
Middle age man. Examine fundus and used 90D. Bilateral
disc cupping, right about 0.8, left 0.6 but definite marked inferotemporal
notching. Asked for IOP which was >25 in both eyes and then mentioned
need for formal visual field testing. Given Humphrey printouts, patient
had classic glaucoma changes that matched his discs.
Young patient, already thinking along the line of secondary glaucomas.
Whilst he took his glasses off, took it from him and he was moderately
myopic. I think it's an important observation. Patient had
classical changes of pigment dispersion but quite subtle in right eye.
Asked about pigment dispersion, risk of glaucoma, risk factors for progression
and management including medical, laser and surgical.
32 year old lady. Seen by GP 4 days ago for right red eye.
Seen casualty 2 days ago by “new” SHO who thought it was uveitis with raised
pressure, gave her dexamethasone 2hrly, levobunolol and cyclopentolate.
Now being seen by you in clinic.
Take history. Essentially what transpires is that the right eye
is not getting better, the vision is poor and she is very upset.
She is angry that seemingly the SHO who saw her was uncaring and rude.
She intends to make a formal complaint. In terms of past history
she is asthmatic and says that since starting the drops, she has been feeling
more SOB. On closer questioning she also mentions the right eye being
red and sore about 16 years ago.
Read the rest of the “vignette”. In fact the patient has a large
dendritic ulcer, cells +2 in the AC but the IOP is normal. There
is also evidence of a corneal scar, probably old.
Basically, you had to explain the problem, the need to change the treatment
i.e. stop beta blocker because of SOB, decrease steroids because it was
herpetic and need for antiviral agents, I mentioned both topical and oral
will be given to her.
I explored her anger a bit more, mentioned that it was difficult for
me to pass judgement on the SHO, mentioned that he was new and that her
concerns will be discussed fully with the said SHO. Also said that
sometimes it can be difficult to know its herpes simplex at initial presentation
and the important thing is that we now knew what were dealing with and
could treat it to the best of our abilities. She seemed to be satisfied
and “acted” less agitated. Then she asked about time off work, she
was anxious not to be absent if possible. Told her there was no absolute
contraindication to going back to work as long as it would not affect her
taking the treatment. But if she is feeling rough and we need to
see her again anyway in 2-3 days time, then she might consider taking a
couple of days off. The decision was hers. Bell rang.