FRCOphth 2 Sheffield 2011 (Passed)
The scenario was explain to a mother who’s child is being treated
for a hypermetropic anisometropic convergent squint with glasses and
now needs patching. She does not understand why the good eye needs
to be patched and wants the child to have squint surgery. You have
to explain why squint surgery is not an option at this stage.
I approached this by asking her to outline her concerns, and to
explain what she understands by her child’s condition. From this it
was evident that she did not understand that refractive correction
is necessary to treat ambylopia. I resolved this by pretending to
show mum with trial frames with the child’s refractive error to
demonstrate how blurred the child’s vision is without glasses. She
accepted this. I then explained how important a clear image is in
the normal visual development of a child. If one eye has a clearer
image than the other, then it is only natural for the child to want
to only use that eye and for the other eye to become lazy. Therefore
the first and most obvious step in treating this is with glasses. I
then outlined how including patching helps to further promote more
visual development in the lazy eye by essentially forcing the brain
to use that eye and therefore develop the pathways on that side.
Mum responds that she understands that this is important but that it
will be extremely difficult to get the child to cooperate with
patching. She feels that is will upset the child.
I responded to this by stating that I would expect any child to be
upset by patching. I understand how difficult and upsetting to force
this on a child, but to bear in mind that the child does not
understand why, but you do. You have to bear in mind that you are
doing this for their future benefit and they will thank you later
for your patience, especially if they decide they want to be in a
career that requires good vision in both eyes such as a pilot. I
also explained that patching can be broken up into smaller chunks
and that there are methods in encouraging the child. I suggested
decorating the patches, rewards charts and time with a play
therapist to demonstrate. I also suggested some information
I explained that squint surgery at this stage would not be
recommended as it would be cosmetic in nature and would do nothing
for the child’s vision. I explained that if ambylopia is adequately
treated that the eye will begin to straighten. Squint surgery can be
an option later on when they are older if this is not successful. I
asked if there were any further questions, which there were none,
and then suggested a follow up appointment to follow up on the
This was a TED station. There were questions on the grading of TED-
I gave Mourits and EUGOGO, and the expected questions on management
which I based on EUGOGO guidelines- lubricants, selenium and
immunosupression. There were CT interpretation- Enlarged muscles
consistent with TED. Tendons not involved therefore distinguished
from myositis. What are the advantages of CT and MRI imaging. I
outlined time, noise, radiation different tissue modalities etc.
When MRI useful in TED? STIR Sequence and in suspected Optic nerve
compression. Had to interpret and MRI demonstrating TED with Optic
Nerve Swelling. Then had to interpret a Hess chart showing bilateral
lateral rectus underaction. Esodeviation of both eyes. Was asked to
quantify- each box means 5’. Was asked how I would manage the double
vision. I outlined occlusion, botox and finally strabismus surgery-
when stable and decompression surgery complete.
Complex Case 1.
Trauma with globe rupture. Was asked how I would manage. Did the
usual history examination. Imaging including x ray and CT orbits.
Was shown an x ray then a CT demonstrating an IOFB. How would I
proceed. I said primary repair with removal of IOFB at later date
(It was in the vitreous) as VR cover not avaialble. Explained
careful consent and prognosis. Outlined how I would approach the
surgery- EUA, peritomy swinging up recti suture choices etc. Asked
about primary enucleation. I stated that I would always aim for
primary repair in the first instance even in the most severe cases
to allow the patient to come to terms with the loss of the eye. Was
asked about sympathetic ophthalmia. I said if wanted to avoid would
need to do enucleation within 2 weeks.
Complex Case 2.
Scenario where you are asked by the medical team to review a 16 year
old girl on ICU with a 6th nerve palsy. History of otitis media 1/12
ago. I outlined bedside VA assessment with hand held chart,
Ishihara’s, pupil assessment, EOM, VF on confrontation. Ask if okay
to dilate patient with medical team the examine optic nerves with
direct/indirect ophthalmoscope. Was shown a picture of gross
papilloedema and asked to describe and then outline what I would do
next. I stated my differentials which included Gradenigo’s syndrome,
SOL- and specifically cavernous sinus thrombosis. Outlined bloods
and imaging and then supplementary tests when patient fit including
formal GVF, orthoptic assessment and fundus photography, Was shown a
GVF showing extremely restricted fields with enlarged blind spots.
Went briefly into management which I said needed multi disciplinary
approach as may need anti coagulation.
Attitudes, Ethics and Responsibilities.
Scenario was where consultant colleague has made a mistake in the
management of one of his patients and wants to cover it up. How
would you deal with this? I started with speaking to my colleague
privately and attempting to outline in a non threatening manner his
responsibilities in being open and transparent. An incident report
needs to be filled in. I would need to ensure that the patient has
come to no harm or that remedial action has been taken. I was then
asked what my next step would be if he did not respond to this. I
stated that I would have an ethical responsibility to report this
and outlined the chain of command from line manager, clinical
director, medical director, chief executive, royal college and GMC.
I was also asked about safe site surgery and to give examples. I
gave incorrect side being done during cataract surgery. I outlined
WHO checklist. Then was asked to define probity- but ran out of
Also had a scenario where I as the consultant have performed a YAG
capsulotomy on a patient who should have had a PRP- how would I deal
with this. I took a 2 pronged approach to this- Firstly I need to
remedy the situation at hand. The patient needs to be recalled an
explanation given and apology and then the appropriate treatment, If
he wishes to make a complaint then I would provide the appropriate
complaints procedures to him. He would have every right to complain.
The 2nd thing that needs to be done is measures to prevent this from
happening again. An incident report needs to be completed and an
investigation into why safeguards failed to prevent an incorrect
procedure being performed. I outlined the traffic light system on
the management of critical incidents.
Evidence Based Medicine.
The CATT study. Explain this study- I went through the non
inferiority concept and study design. Was given the table comparing
regular and monthly doses of lucentis and avastin. Was asked to
interpret this. Explained that essentially avastin non inferior but
not equivalent. Pointed out where the data was inconclusive ie when
it could be inferior and non inferior at the same time. Was asked
about which drug I would give my mother in law- I said lucentis.
Can’t ignore the trend towards lucentis in the paper. Also cannot
comment on safety as the study not powered for safety. Then was
asked about teaching laser. I outlined laser safety rules, laser
safety officer, laser safe rooms, googles etc.
Cornea and Lid
Bilateral Lower Lid Ectropion with
Punctal Eversion and Stenosis. Asked for mechanisms of ectropion
development- ie involutional, cicatricial etc. Was asked how to
manage- I went for LTS with a medial spindle. Patient also needs
punctal dilatation and syringing and probing- which requires a local
Pseudophakic patient with a PI and a
Trabeculectomy. Small amount of Anterior Chamber Activity. My
differentials were previously treated ACG or a form of inflammatory
glaucoma. Was asked how I would treat- outlined medical and finally
augmented filtration sugery.
Aniridia combined with Congenital
Glaucoma. Obvious Haab’s Striae, enlarged corneal diameters and
aniridia. Management?- I said EUA making sure to check IOPS with
Glaucoma and Anterior Segment
HSK- large vascularised corneal scar.
Management- I divided into initial acute phase and then long term
management. Topical Acyclovir treatment, topical steroid treatment
and then consider long term prophylaxis with oral acyclovir if
recurrent- quoting the herpes eye disease study.
Cataract assessment- man
pseudophakic right eye with pigmentary changes on endothelium. NS++
other eye. Pupils not dilated. Was asked whether he would dilate
well. I said no- he probably had PXF? Was asked how to manage this-
I went through using intracameral phenylephrine, iris hooks etc.
Prosthetic shell one eye, aniridia
other eye with mild cataract. Asked to consider cataract surgery. i
said was reluctant as aniridia pro inflammatory condition and likely
to trigger glaucoma and or corneal decompensation. Was asked if I
had to do what precautions I would take- dispersive viscoelastics,
BSS+, minimum phaco power etc...
There was also a patient with a Peter’s anomaly. When asked how I
would manage, I went for optimising refraction. Was asked what kind
of refractive changes I would expect- I went for irregular
Medicine and Neurology
Examine a male patients lower limbs.
He has a scaly rash- Psoriasis. Then had to look at hands and
identified features of psoriatic arthritis- onycholysis, swollen
joints etc. Was asked what other joints involved?- All others are.
What are the ocular features-?I answered uveitis.
Examine pupils female patient. Asked
lights to be turned down. Had an obvious afferent pupillary
defect.Then asked to use direct to examine optic nerves. There was
bilateral optic nerve pallor one side more than the other. Asked for
differentials- optic neuritis, SOL, trauma, radiation, AION, NAION,
toxic etc. Then asked how I would investigate- I outlined the blood
tests and then imaging (MR with gadolinium).
Confrontational VF on female patient.
Bitemporal hemianopia with a nasal defect on one side. Was asked
differential- tumour compressing optic chiasm most likely pituitary
adenoma. Was asked to explain why she had double vision. I did a
cover test and EOM and identified an exotropia. Was asked to look at
the glasses- which had a prism. Which way is the prism?- Base in.
She has double vision because of hemi field slip/post fixation
blindness. How would I manage?- Needs imaging preferably MRI with
Gadolinium including the Pituitary. Needs input from endocrinology
and possibly neuro surgery.
Slit lamp examination of fundi of male
patient. Had pigmentary changes both maculae and also surrounding
optic discs. Also noticed buried drusen. Was asked differentials-
this was angioid streaks with previously treated membranes. Was
asked associations of angioid streaks - gave the usual and how
membranes would be treated. I said anti-vegf injections now, but
also stated that PDT also very effective in the past.
Strabismus and Orbit
Take a history. Young man who suffered
a signifiant head trauma and had resultant double vision. Had to do
an exam. Pupils showed a fixed dilated left eye. Aberrant
regeneration of third nerve obvious on EOM. How would I manage-
suggested occlusion, prisms and botox if possible. When stable for
at least 6 months can consider squint surgery- would need a
Take a history. Female patient with
red eyes which was treated with ibuprofen in eye casualty. Previous
RD surgery on one eye (RE). Thyroidectomy for hyperthyroidism. Has
double vision. Do an examination. I checked for proptosis by looking
overhead but i couldn t be sure of proptosis on the RE. Asked to use
exophthalmometer. Wasn’t necessary. There was restriction in upgaze
of the right eye and a buckle was evident nasally. My differential
included mechanical restriction or TED or combination of both. I
suggested that confirming the cause then treating the cause is the
most appropriate course of action. May need IR recession.
Slit lamp examination of young man who
suffered blunt trauma. Had iatrogenic dilated eye, zonular
dehiscence, mild cataract, cryo scars and finally a buckle. Was
asked what kind of tear he would have had- I said dialysis, and he
most likely had break ora occlusive buckling. Was asked what would
be other signs of previous RD surgery- I said tobacco dust, presence
of oil or a buckle. Was asked how I would manage the cataract. I
went for an anterior segment approach bearing in mind that there is
a high risk of a dropped nucleus- use iris hooks/ tension ring etc.
Indirect examination of male
patient. Normal eye right eye. Left eye no view due to cataract.
Asked what I would do next- the answer was B scan. What are you
expecting? Retinal Detachment.
Slit lamp examination of posterior
pole. Macular hole with positive watzke allen sign. Was asked about
types of macular hole- I outlined the 4 grades then aetiology. Was
asked about prognosis and surgery. Said better outcomes with better
pre op VA. Surgery more likely to be considered in younger patients
with shorter duration of visual loss (less than a year) with high