Candidate seven Date: March, 2000
Location: Moorfield Eye Hospital, London
The examiner asked me to ask the patient ( a woman in her 60s) some questions. There was no obvious external signs. The answers suggested that the patient was recently admitted for a painful red eye and had had laser treatment.
Slit-lamp examination revealed bilateral peripheral iridotomies. The right eye had iris atrophy and glaucoflecken. Questions on the predisposing factors for angle closure glaucoma and its treatment.
Indirect ophthalmoscopy with 78D on the slit-lamp. The patient had a left branch retinal vein occlusion and sectorial pan-photocoagulation. Questions on the management of branch retinal vein occlusion based on the Branch Retinal Vein Study Trial.
Ocular motility examination. I began with cover/uncover test and noticed a right hypertropia. I commented on this and proceeded to perform the three step tests. The patient had a left fourth nerve palsy. I was asked about the muscle sequelae of fourth nerve palsy based on the Hering's and Sherrington's law. The other examiner wanted to know how I would test for cyclotorsion ie. the use of Maddox rods.
Slit-lamp examination of the anterior segment. The patient had a right corneal graft and abnormal iris stroma showing iridocorneal fibrous attachment. I made a diagnosis of Reiger's anomaly.
The examiner wanted to know the management of congenital glaucoma and the causes of childhood glaucoma.
Slit-lamp examination of the anterior segment. The patient had heterochromia and slit-lamp examination revealed left heterochromic cyclitis.
Questions on the management of this condition and the complications which may occur during cataract operation (poor dilatation and Amsler's sign).
Clinical medicine / Neurology
Ocular motility examination. The patient had obvious bilateral thyroid eye diseases. There were some restriction on upgaze otherwise the movement was full.
I was then asked if I noticed any other physical signs. I mentioned arachnodactyly and proceeded to demonstrate that the patient had co-existent Marfan's syndrome (arm span longer than height and high arch palate). I was asked to list the possible ocular complications of Marfan's syndrome.
Direct ophthalmoscopy of the fundus. The patient had a right optic atrophy. I was asked to give a differential diagnosis and the type of investigations that I would perform. The patient turned out to have a right optic glioma but there was no evidence of proptosis.
Pupillary examination on a middle-aged women.
She had anisocoria but without ptosis. Neither eye responded to light but on accommodation, the larger eye constricted. The response of the small pupil is difficult to see. I mentioned that she may have bilateral Adie's pupil with the smaller pupil being the long-standing one. I asked to see the iris on the slit-lamp. There were vermiform movements in both eyes.
I asked to examine the knee reflexes but the examiners appear satisfy with the diagnosis and did not want me to proceed.
I was asked to observe the patient's eye and perform any examination as appropriate.
I noted the presence of a down-beat nystagmus and went on to examine the nape of the patient. There was no surgical scar there. I mentioned the possibility of Arnold-Chiari's syndrome as a cause and that I like to examine the upper limbs for any evidence of syringomyelia. The examiners appeared happy with the response but did not want me perform neurological examination of the upper limb.
Pupillary examination of a middle-aged man.
The patient had a mild right ptosis and small pupil. There was no heterochromia. I diagnosed right Horner's syndrome and proceeded to examine the neck, right hand muscles and the pulmonary apex but there were no signs to indicate the cause of the Horner's syndrome.
The examiner asked me the pharmacological testing for pre and post-ganglionic Horner's syndrome.
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