Candidate 12 Centre: Glasgow
Date: Sept., 2000
Ophthalmology
Case one
I was asked to examine the anterior segment of a woman in her 70s with a slit-lamp. She had had a right trabeculectomy and advanced cupping in this eye. There were no signs of pseudoexfoliation syndrome or other secondary changes. I diagnosed primary open angle glaucoma.
I was grilled on the different types of anti-glaucoma treatment and their side-effects.Case two
Again a slit-lamp examination. The patient had a left lamellar keratoplasty. There was no other signs to suggest the reason for the graft.
I was asked about the post-operative management of corneal graft and the advantages and disadvantages of lamellar vs penetrating keratoplasty.Case three
Fundal examination using a 90D lens. The patient had a greyish lesion which is slightly elevated located in the periphery of the left posterior segment. Questions on the differential diagnosis and treatment options for choroidal melanomaCase four
This is again a slit-lamp examination. The patient had a right iridodialysis and stallate cataract. I made a diagnosis of blunt ocular trauma. I asked to examine the posterior segment for choroidal rupture and possible retinal changes from detachment surgery. However, there were no such changes when I examined the fundi with a 90D lens.
One of the examiners asked me about the management of traumatic hyphaema and the possible causes of raised intraocular pressures following blunt trauma.
Medical Ophthalmology
Case one
I was asked to examine the anterior segment of a young girl with thick plus lenses. I found bilateral aphakia and told the examiner that I suspected that she may have Marfan's syndrome.
I was asked about the characteristic features of Marfan's syndrome which this patient had in abundance (long fingers, high arch palate, arm span longer than height.) I was asked to listen to her chest and she had signs of diastolic murmur and I gave a differential diagnosis of aortic valve incompetence and aortic root dilatation. I was asked what medication I would prescribe the patient and I suggested beta-blockers and the examiners seemed satisfied with the answer.Case two
The patient was a young woman with a dilated left pupil and I was asked to perform pupillary examination.
There was light-near dissociation. I diagnosed Adie's pupil and told the examiner that I would also like to examine the left iris on the slit-lamp for vermiform movement and also test the patient's tendon reflexes for signs of Holme-Adie's syndrome.
The examiners then asked about the differential diagnosis of light-near dissociation. Most of the questions centred on Argyll-Robertson's pupils and the site of the lesion. Then I was asked how syphilis can affect the eye.Case three
I was asked to examine the hands of a patient who had symmetrical joint deformities characteristic of rheumatoid arthritis. I was asked about the ocular signs which may occur in rheumatoid arthritis.
I was then asked to examine the upper lids of the same patient. He had bilateral ptosis which appeared to be variable but prolonged upgaze caused the ptosis to increase. I diagnosed myasthenia gravis. The examiner wanted to know if I could link the rheumatoid arthritis to the ptosis. I mentioned penicillamine (penicillamine can cause drug-induced myasthenia gravis). The examiners appeared surprised that I could produce the right answer so quickly.Case four
Visual field examination of a middle-aged man. He had a left congruous homonymous hemianopia. There were no other neurological deficits. I mentioned that the lesion is probably at the occipital lobe.
The examiners wanted to know how I would investigate the patient. I mentioned physical examination for possible sources of emboli (arrhthymia, valvular diseases, carotid stenosis) and measure the blood pressure for hypertension.Case five
After case four, the examination became mainly an oral examination.
The two main questions were:
a. What points would I include if I have to give a lecture to a group of casualty doctors on eye signs which may be potentially life-threatening? (third nerve palsy, papilloedema, bilateral subconjunctival haemorrhage from basal skull injury etc)
b. A patient developed shortness of breath 24 hours after a prolonged vitreoretinal surgery. What is my differential diagnosis? (The question revolved mainly on pulmonary embolism).