(Appearing in Sept, 2003)
A 60 year-old woman with bilateral myopia
of -8.00D and cataract. Explain to her how you will carry out the operation
ie. local or general anaesthesia and the choice of implant for the operation.
(Suggestion: Ascertain if the patient
wishes to have operation. Explain how the new lens may affect the vision,
whether the patient prefer to maintain the same refraction or wishes for
emmetropia. Is she happy with local anaesthetic and if not is there any
contraindications to general anaesthesia?)
Scenario 2: (Appearing in Sept, 2003)
You are given a referral letter from a
GP about a 23 year-old footballer with an unilateral red eye. The patient
has been treated with chloramphenicol eyedrop without improvment. You are
asked to ask the patients some questions and decide on the appropriate
(The patient turned out to have Reiter's
syndrome. The candidate did not ask about the sexual history and systemic
enquiry regarding backache etc as expected by the examiner. In addition,
the examiner expected the candidate to inform the patient the effect of
mydriatic on his football career.)
A 50 year-old man with bilateral advanced
glaucoma has just failed his Estermann visual field and you have to tell
him that he should not be driving.
(Suggestion: Explain the finding
to the patient. You may say something like ' We have performed a special
test called Estermann test because of your glaucoma. Do you know why we
carry out this test?' Find out the patient's need to drive. Is there any
support at home?)
A 40 year-old woman with a choroidal mass
returns for her investigation. The chest X-ray suggests the presence of
(Suggestion: Verify that the chest
X-ray belongs to the patient and let the patient ask the questions for
example ' We have been doing some investigations since we discover a lesion
within your eye. Do you know why we are doing the investigations?' find
out the expectation of the patients then say 'The results of the chest
X-ray have come back and there are something showing on the film' or alternatively
you can say ' I am afraid we have bad news for you' and the patient will
likely to say 'Is it cancer?'. This will be better than come out with sentence
like ' You have cancer!')
A 50 year-old man with a painful right
blind eye. Advise regarding the various options for treating his painful
eye including enucleation or evisceration.
Ascertain the severity of the pain and
the patient's desire of keeping an intact globe. If enucleation is contemplated,
consider the need for AE)
A 63 year-old man returns 4 weeks later
for a follow up cataract visit. Refraction shows that a wrong lens has
been inserted resulting in a hypermetropic shift. The patient is unhappy
that he could neither read or see distance without glasses. Explain to
him what has happened and the various options open to him including lens
exchange and contact lenses.
Find out how inconvenience it is for the
patient. Whether the patient was hypermetropic before the operation and
what he had been told about the final refraction prior to the operation?
Explain the varioius options open to him.)
A 35 year-old has had two failed corneal
graft for heretic corneal disease. The cornea is heavily vascularized.
He likes to have another corneal graft but you know there is little of
a successful outcome. Explain to him why you think a re-graft is not appropriate.
Find out why the patient wants a re-graft
and his understanding about the success rate. Is he concerned about the
cosmetic effect of a leucoma? In which case cosmetic contact lens may be
A 69 year-old woman is referred by her
GP for possible cataract operation because of very poor vision in both
eyes. After examining the patients, you discover that she has minimal cataract
and the poor vision is caused by bilateral disciform macular degeneration.
Explain to the patient why you think that cataract is inappropriate.
Explain to the patient what the problem
is and why cataract extraction is unhelpful. Use the analogy of a camera
to describe the eye for example: ' The lens of a camera is similar to the
lens of your eye and the film within the camera is similar to the back
of your eye. When the lens is damaged we can replace it with a new one
which is similar to a cataract operation. However, if the film is scratchy,
changing the lens may not alter the image captured on the camera. The problem
you have is similar to a scratchy film so cataract operation will not improve
your vision.' If there is a model of the eye present, use it to illustrate
her problem. Suggest blind registration or partial sighted registration
and low visual aids.)
A woman has a 2 year old child with bilateral
retinoblastoma. She is planning a second pregnancy and likes to know the
risk of a having another child with retinoblastoma.
Find out how much the patient knows about
the conditions and the inherited patterns. Is her partner aware of her
desire of having a second child? Is it possible for the partner to be present
during the consultation?)
You are the only doctor in the minor operating
room and the eye unit. A woman is referred directly to you by her GP for
a cyst removal from the right upper lid. However, the lesion appears to
be a large basal cell carcinoma. You have no experience of excisional biopsy
in this area. Explain to the patient why you are not going to carry out
the operation on that day.
(Suggestion: Find out how much the woman
has been told about the lesion. Explain to her your concern and the need
for her to be seen by somebody senior. Apologize for the inconvenience
cause and arrange an early appointment for consultation.)
A 60 year-old man was diagnosed with glaucoma
3 months ago. He was given a beta-blocker to be applied topically twice
a day. However, the intraocular pressures remains high and there is deterioration
of the visual field. His wife says he is not taking the medication regularly.
Find out if he has been taking the medications regularly and explain to
him the importance of taking the glaucoma medication.
(Suggestion: Drug non-compliance is a
common problem. Avoid confronting the patient as the patient may deny it.
Instead begin by asking if he has had problems with the eye-drops such
as breathlessness and any problems applying them such as rheumatoid hands.
Then explain to him the deterioration of the visual field and the risk
of blindness and losing his driving license. Mention the alternative such
as latanoprost or trabeculectomy.)
Consent for ptosis- patient wants general
anaesthesia, you have to explain the advantages of local anaesthesia.
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
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
Glaucoma with extensive defect, asked to
advise on stopping driving (she went on talking for 15 minutes).DVLA tell
woman not to drive, patient insistent on continuing
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!
Take history from and consent patient with
involutional ptosis. Patient wanted a consultant to operate on her and
requested a GA. I had to talk her out of both
Take a history from a diabetic who has
presented with sudden loss of vision ( had vitreous haemorrhage).Obtain
informed consent for PRP
Age-related macular degeneration, consent
for FFA, tell patient it is not amenable to treatment.Counselling a 50
year old librarian for cataract surgery. The patient is myopic with refraction
of RE -15.00D (operating eye) and LE -14D (6/9). Biometry aim to leave
at -3.00D. Questions asked by examiners:
What would be her risk for retinal detachment?
Questions asked by patient:
• Can she be left to wear glasses
in the distance but read unaided?
• Why does she need to have the
other eye done despite the good vision?
• Discussion on anisometropia.
• Can she have a general anaesthesia
as she is scared or sedation?
28 year old professional footballer with
low back pain and red painful eye. Asked to take a history and discuss
management. Had to take his sexual history!
You are an SHO in the preassessment clinic
for cataract surgery.The patient is a myope with prescription of -8.00
D and -14.00D and has been listed for a left cataract surgery
with a post op refraction aim of -3.00D. Counsel the patients about the
risks and benefits of the cataract surgery and the need to leave her a
bit short sighted , need for a second cararact surgery soon.
Woman 55 had “bleed” in the eye 2 years
ago and also complained of visual obscurations lasting 30 mins. This was
uniocular. On further questioning had visual auras like “shimmering lights”
Asked for headaches – no headaches
Asked for BP and DM and IHD and palpitations
– history of BP and mild IHD andpalpitations.
Bleeding in eye sounded like a vein occlusion
Examiner wanted to know what I thought
of the problems were and what I would do in clinic. Mentioned that I would
like to clarify the bleed – then told me it was BRVO and VA was 6/9. Mentioned
that sounds like migraine but also due to PMH would like to examine carotids
and CVS to exclude emboli.
Asked for features in history that would
support either differential.
30 mins was too long for embolic disease
and auras are not typical – more like migraine. But in view of history
I said that carotids had to be examined. Examiner wanted to know if it
was really necessary to scan carotids in this case – said yes it is cheap