Candidate 69                                                   Centre: Southampton 
Final MRCOphth                                                             Date: September, 2005
Pathology CRQ's:
  • Generally thought by all to be very tough.
  • Lots of stuff not from previous years and not on this website.
  • Lots of histopath and Lots of immunology!
  • Have to write fast just about enough time.
  • From what I remember: 
    • Muscle stuff – probably kearns sayre, ragged red fibres etc
    • Cornea - ?  kertoconus from history but picture looked like something else. At least a couple of graft related questions – one herpetic ( ? also acanthamoeba )
    • Questions on cornea and immunology
    • Melanoma – but not straight forward
    • Epidermoid/dermoid cyst –  Questions re other ORBITAL cysts.
    • Lymphoma ( I think ) – again questions on immunology
    • Lots others the I can't remember ( maybe I'm psychologically blocking it out… )


Some very hard questions, and at least six on statistics, lots on uveitis, but overall fair. Lots of time, - finished with hour to spare.



Case 1
Middle age lady – look at fundus on slit lamp – undilated - cupped discs – one eye was not clear – could have been either fully cupped with sloping edges – or 0.3  - I went for 0.3 – was wrong ! Questions on how I would manage. 

Case 2
2nd patient is a slit lamp examination too. ' Look at ant segment and post segment'. The right eye was prosthetic ! Left had bleb, ECCE scar, two large surgical PIs and a stitch in iris between pupil and one of the PIs.  IOL and PCO. Disc was cupped. – questions on how I would manage a stuck down pupil. Examiner was trying to get to the fact you can cut the pupil on purpose when doing an ECCE if it is not big enough.  Questions on would I do this under topical (he wanted me to say no as it is an only eye and difficult surgery ) 
Then shown Humphrey field of a right eye with inferior defect. Described. Examiner asked as bell went whether this could be from this patient – I said yes  - he said you sure? Then he pointed to the fact it was a right field?  The patient had a right prosthetic eye. I laughed and said that's not fair ! He smiled as I left the room…..

Comunications skills

Easy. Had to consent somebody ( not an actor – probably an observer from clinic ) for cataract surgery. 55 yo librarian – high myopic in both eyes – one eye still good vision. Plan is to leave him – 3.00 and do the other eye subsequently. Straight forward. Remember to assume NO knowledge from patient. He didn’t even ‘know why he was here’. Always ask them if they have any questions.
Finished with 7 mins to spare.

Anterior segment

Case 1
Lady with trab, endothelial beaten metal appearance and pupil distortion: said ICE – asked about gonio appearance.

Case 2
Guy with bilat corneal dystrophy – looked like granular – asked about how I could tell – said family history  - pt said mother had it but none of children. Examiner said can it still be granular – I said yes as autosomal dominant – but doesn’t mean half his children have to get it – just means each child has 50 % chance of getting it. Questions re how it presents and treatment – went on to talk about types of grafts and advantages and disadvantages of the types. Then about complications.

Case 3
Third patient – marked posterior blepharitis – but no obvious rosacea. Pingeculum temporally – but growing onto cornea.. pigment on endothelium ? old Kp’s – also had some TI defects – bell went.

Motility and Neuro-ophthalmology

Case 1
Scenario of middle age lady with severe headache and unilateral ptosis. – how would you proceed? Was trying to get at a painful Horners – and was trying to get me to say carotid dissection. Took ages – he really had to draw it out of me. 

Case 2
Young guy with  right exotropia. Cover test and motility. Then questions of differentials. – wanted basic principles.

Case 3
Third patient – 5-6 yo boy – asked to fields! He had very very constricted field in RE – was told he was NPL in other eye and 6/36 in the right. Asked for differentials. Again become very drawn out….

Medicine and ophthalmology

Case 1
Had the famous Liz Graham – was actually very nice…
Patient in chair – asked to do indirect – had a strange type of what I thought was PRP – no nvd/nve – looked at other eye too – looked same. Then asked to do direct . no nvd – but said it looked pale. Couldn’t get a view of left disc – no matter how much I tried…not good …..
Talked about diagnosis – cut to the chase and said diabetes. Asked about : causes of visual loss in diabetes, went on to how you would consent for PRP – and driving. Talked about management of Hypoglaecemia – they wanted specifics of doses of iv glucose and wanted complications of Glucagon ( the examiner told me as I left it makes you vomit ) . asked to examine the same patients hands. –  did not go well – but basically had peripheral neuropathy and muscle wasting. Got me to test power in hands – and got asked about muscle innervation. Then asked to do upper limb reflexes – bell went half way thru….

Posterior segment

Case 1
Indirect in one eye – was not getting view of disc – was starting to get worried – then got a fleeting glimpse – had myelinated nerve fibres. They didn’t ask me to stop so I went to periphery and saw a big naevus – went through all the features. Asked to look no more. Asked about myelinated nerve fibres and whether they have any consequence. Asked about features of benignity vs malignity in naevus. Asked about management – didn’t even get into specifics and ended up talking about looking for spread……

Case 2
Next patient ( slit lamp ) had hemiretinal vein occlusion – and macular oedema – asked about how to work up patient. Got onto treatment and settings of laser. Then on to management of CRVO – and then onto how to tell between ischaemic and non ischaemic. Said RAPD and vision and appearance. Asked what else – I made the mistake of saying electrodiagnistics – then got asked about them – NOT GOOD !! – apparently you can also do visual fields. Asked about why you do PRP etc.
Then at end was asked about other treatments for macular oedema – said intravitreous triamcinolone – asked about complications as I was leaving – said raised IOP.


I was no where near as bad as I thought. Quite a few times I said something eg  X  for a differential –  and they kept pushing me and at the end they said what about  X ‘  - even though I had said it earlier!–  I just stayed quite and said 'oh yeh !’' . 
General advice : just be really confident and keep it simple.

Not sure how I did? If I fail it will be on path – fingers crossed.

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