Test 39
(Matching Paper: Retina)

In response to considerable discussion the Examinations Committee of the College has decided to update the format of the Part 3 MRCOphth Examination from April, 2003.

An extended matching paper will replace the existing MCQs and they will be no negative marking. The test will probably be easier than the previous format. To familiarize the candidates with the new formats, test 34 and onward will follow the new style as described below by the College.
 

40 questions over a 3-hour period. The questions will be divided as follows. 5 pathology questions 5 microbiology questions 15 general ophthalmology questions 15 Medicine and Neurology in relation to ophthalmology Extended matching questions are multiple choice items organized into sets that use one list of items in the set. The extended matching set includes four components  1. a theme  2. an option list  3. a lead in statement  4. at least four item stems, as illustrated below  This will involve 40 questions (probably 200 stems) over a period of 3 hours.

1. Match the fluorescein angiographies (a-d ) with the most likely options (A-N) listed below:
 

A. background diabetic retinopathy with       significant macular oedema B. background diabetic retinopathy with      microaneurysms C. proliferative diabetic retinopathy  D. proliferative diabetic retinopathy with      vitreous haemorrhage E.  angioid streaks F.  sickle cell retinopathy G. subfoveal choroidal neovascularization      in age-related macular degeneration

H. juxtafoveal choroidal neovascularization      in age-related macular degeneration I.  extrafoveal choroidal neovascularization      in age-related macular degeneration J.  central serous retinopathy K. macroaneurysms L.  post-operative cystoid macular oedema M. branch retinal vein occlusion N.  central retinal vein occlusion

 

a.	Answer H. The picture shows an area of hyperfluorescence beneath the retina at the  border of the fovea. The most likely diagnosis is juxtafoveal choroidal  neovascularization in age-related macular degeneration.
b.	Answer E. The picture shows areas of hyperfluorescence under the retina (note retinal vessels run over them) radiating from the optic disc. These features are typical of angioid streaks.
c.	Answer B. Background diabetic retinopathy with microaneurysms. The fluorescence angiography is at the venous phase and exhibits multiple spots of hyperfluorescence typical of microaneurysms. There is no evidence of significant macular oedema.
d.	Answer K. The fluorescence angiography shows an area of hyperfluorescence arising from the second order retinal artery with a surrounding area of hypofluorescence (from exudate or haemorrhage). This is typical of a macroaneurysm.

2. Match the following findings (a-d) with the studies (A-L) listed below. 
 

A. DCCT B. BVOS C. CVOS D. UKPDS E. MPS F.  TAP

G.  ETDRS H.  DRVS I.   AERDS J.   OHTS K.  DRS L.  EVS

 

a.	This study showed that focal argon laser photocoagulation reduced visual loss in patients with macular oedema due to branch retinal vein occlusion and a vision  of 6/12 (20/40) or worse . Answer B. BVOS (Branch retinal vein occlusion) looked at the benefit of laser on macular  oedema and neovascularization in branch retinal vein occlusion. The result showed  that BRVO with a duration of 3 to 18 months and a visual acuity of 20/40 or  poorer attributable to macular oedema benefited from focal argon laser  photocoagulation. Eyes with BRVO involving at least a 5-disc-diameter area of  retina were randomized to photocoagulation treatment versus observation. 61%  of the untreated eyes developed vitreous haemorrhage versus 29% of the treated  eyes.
b.	This study showed there was no difference in outcome between immediate  vitrectomy and intraocular antibiotics alone if the initial vision was hand motions  or better. Answer L. EVS (Endopthalmitis vitrectomy study) showed that there was no difference  in outcome between immediate vitrectomy and intraocular antibiotics alone if the  initial vision was hand motions or better. However, if the initial vision involved light  perception only, patients treated with vitrectomy and antibiotics developed a better  final visual acuity and media clarity. In this group of patients with light perception  only, vitrectomy compared with tap plus antibiotics resulted in increases in the  frequency of 6/12 (20/40) or higher final visual acuity (33% versus 11%), 6/30  (20/100) or greater visual acuity (56% versus 30%), and a 50% decrease in severe  visual loss
c.	This study showed that an intake of vitamin C and E, carotene and zinc protect the progression of moderate age-related macular degeneration to advanced macular  degeneration. Answer I. AERDS (age-related eye disease study) showed a statistically significant degree  that the intake of vitamins C (500mg), E (400IU) and beta carotene (15mg) and  the minerals copper (2mg) and zinc (80mg) protects the progress of moderate AMD  to advanced AMD in 25% of patients. Also these same nutrients reduced the risk  of further vision loss in advanced AMD by 19%. The results are important for those  patients who already have AMD to a moderate degree or those with severe disease  in one eye. However, this study does not apply to patients who have no signs of  macular degeneration or who have early forms of the disease. Also, lutein was not  used in this study. .
d.	This study showed that the treatment of predominantly classic CNVMs in wet  age-related macular degeneration with photodynamic therapy (PDT) reduced the risk of losing three or more lines of vision. Answer F. TAP (Treatment of age-related macular degeneration with photodynamic therapy study) showed that PDT is useful in patients with predominantly classic CNVMs  attributed to age-related macular degeneration.

 

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