Candidate 63                                                   Centre: Newcastle
Final MRCOphth                                                             Date: March, 2005
Constructed Response Paper

(1) Retinoblastoma

  • Describe histological slide: FW rosettes and fleurettes
  • Prognostic factors
  • 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
  • Ultrasound characteristics

(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?

(5) Vasculitis

  • What is the clinicopathological classification?
  • Wegener’s and role of ANCA
  • Describe histological slide
  • Complications of Wegener’s

(6) Pleomorphic adenoma

  • Describe CT
  • Describe histological slide
  • Malignant lacrimal gland tumours

(7) Endophthalmitis

  • 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.

(8) MRSA

  • 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

(9) Acanthamoeba

  • 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 degeneration
  • 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 features?

(12) Retina

  • Histological slide of retina showing all the layers.  Mark on the drawing where you would expect the pathology to be:
  • Hard exudates
  • Retinitis pigmentosa
  • Cotton wool spots
  • Glaucoma
  • Sturge-Weber

(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

Clinical Examination

Anterior segment disorders

Patient 1
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.

Patient 2
Classical case of OCP.  Management and complications fully discussed.

Patient 3
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

Patient 1
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.

Patient 2
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 of DOA.

Patient 3
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

Patient 1
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.

Patient 2
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

Patient 1
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.

Patient 2
90D slit lamp.  Elderly lady with a choroidal naevus.  Asked about management.

Patient 3
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

Patient 1
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.

Patient 2
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.

Patient 3
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.

Communication skills
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.

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