Test 41
(Matching Paper: Ocular motility)

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 Maddox rod tests results (a-d ) with the most likely diagnoses (A-H) listed below.
    All the patients have a white Maddox rod over the right eye and a red Maddox rod over the 
    left eye:
 

A. Right orbital floor fracture B. Left thyroid eye disease C. Right fourth nerve palsy D. Left fourth nerve palsy

E. Right sixth nerve palsy F. Left exotropia G. Right complete third nerve palsy H. Left complete third nerve palsy

 

a.	Answer F. The patient has crossed diplopia and this indicates either  exotropia or exophoria in either eye. From the options available, F is the most likely diagnosis.
b.	Answer A. The appearance of the Maddox rods suggest that the right eye is lower than the left ie. there is a hyperphoria. From the  options available, right orbital floor fracture is most likely to  be the diagnosis as the eye may become depressed due to trapping of the inferior rectus muscle.
c.	Answer C. Right fourth nerve palsy. The affected eye has hypertropia and cyclodeviation.
d.	Answer E. The patient has uncrossed diplopia and the diagnosis is either a esophoria or esotropia. Given the options the most likely diagnosis is a right sixth nerve palsy.

2. Match the following findings (a-d) with the most likely cause or site of lesion (A-N) listed
    below. 
 

A. Moëbius syndrome B. Duane's syndrome C. Brown's syndrome D. blow out fracture E. right fourth nerve palsy F. left fourth nerve palsy G. right superior rectus palsy

H. left superior rectus palsy I.  infantile esotropia J.  accommodative esotropia K. non-accommodative esotropia L.  intermittent divergent squint M. consecutive esotropia N.  consecutive exotropia

 

a.	A 36 year-old woman complains of vertical binocular diplopia in the primary position.  Examination with a torchlight reveals a left hypotropia in the primary position. With the  head tilt to the right and alternating cover test performed, there is a right hypertropia but no tropia is present with the head tilts to the left. Answer E. In fourth nerve palsy, the affected eye tends to be hypertropic. However, if the affected eye is the fixating eye, the unaffected eye may become hypotropic. With the head tilt to the affected side, the deviation is revealed or increased.
b.	A 6 year-old girl had bilateral esotropia and absent facial expression. There are also punctate  corneal staining due to exposure kerapathy. Corneal sensation appears normal. Answer A. The findings are those of Moëbius syndrome.
c.	A 7 year-old girl has a right esotropia measuring 40D for distance. Examination reveals a  visual acuity of RE 6/24 and LE of 6/12. Cycloplegic refraction shows  RE +6.00/-1.25X40 and  LE +5.5/-1.50X145. Wearing glasses with the prescription of RE +4.5/-1.25 X 40 and LE +4.00/-1.50 X 145. The esotropia is reduced and measured 4D Answer J. The patient has a significant esotropia and hypermetropia. The esotropia is significantly  reduced with glasses correction. .
d.	A 55 year-old has a right constant exotropia and poor vision due to a macular  chorioretinal scar from congenital toxoplasmosis. Examination reveals a large  exotropia measuring 42D. Surgery was performed to reduce the exotropia.  Post-operatively the patient develops a slight esotropia measuring 5 D. Answer M. Consecutive esotropia refers to .

 

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