VIVA’s

1) Patient  investigations

Lead in paragraph given regarding 32 yr old male with 2/52 Hx of vertical diplopia.Asked for DDx

Said MG,TED,CN 4 palsy

Given Hess chart of CN 4 palsy-Asked about muscle sequelaeetc, management and surgical options.

Then given BSV asked whether significant diplopia.(Neither examiners sure if this was the same patient’s BSV.)

2) Patient management1

Lead in paragrapgh given. Hyperopic female had trabeculectomy 1/7 ago. AC is flat post operative. How would you manage?

Subdivided answer into  -low IOP (overdrainage or leaking bleb)

                                                -normal to high IOP (aqueous misdirection, choroidal effusion)

Discussion on Mx of aqueous misdirection, leaky blebs etc.

3) Patient management 2

Lead in statement of Gentleman 62 yr with HT,DM and BPH on Tamsulosin.Shown a picture with mid dilated pupil and nuclear sclerosis. Discuss issues regarding photo: non dilating pupil from DM + tamsulosin. Management of pupil + IFIS - Approached pre-op, intra-op and post-op.

4) Attitudes, Ethics

Consent for cataract surgery. What would you mention?

Down syndrome patient of 62 yr of age in clinic, family present.Consent?

Same patient who’s parents pass away and not mentally capable of looking after their  estate. Consent for cataract surgery.

5) Audit, research and EBM

Treatment options for CNVM asked.

Discussion around licenced, off licence and off label.Asked about the evidence for Avastin at present.

How would you address sterility in your unit! Broad question, discussed theatre air flow, autoclave etc. Asked me about gloves and mask wearing. Had a brief discussion about the difficulty of treating C. Diff

This was a 5 minute waffle, not sure wat was plotting here.

6) Communications

Given 10 minutes to prepare.

Statement starting: DVLA is the authority in charge of licensing drivers in UK. 62 yr old female with glaucoma comes to clinic her HVF of the RE total upper field loss LE complete loss of field with only central island.VA is 6/6 BE. You see this patient,she may have a few questions for you.

Started off with brief history of surgery and topicals.Patient delighted with her vision. Nothing volunteered regarding driving, so I popped the question. Said she was driving of course, no hassles. Said we had to do Esterman binocular field, but prepped the patient that it was highly unlikely that she would pass for driving. Patient emotional but eventually accepted after explanation.

OSCE

1) Medicine and neurology

30 minute combined station!Lovely

-          Patient with vertical diplopia, AHP to the right.Asked to take brief history and examine. Pt had surgery while ago for vertical diplopia. Had no diplopia on Parks 3 step, only illicited on dextroversion and elevation. Thought patient had bilateral IOOA and right SOOA. Only discussed the signs,wasn’t asked diagnosis. Examiner suggested Right SR underaction. Wasn’t quite sure.

-          Pupil involving 3^rd nerve palsy

-          Patient with RA-discussion regarding her meds (plaquenil). Looked for ocular side effects of drug, management in clinic. Wanted RCOphth guidelines for screening. RA’s ocular manifestations

-          Patient with torsional nystagmus and cerebellar signs. Asked to illicit some of the signs.

Phew!...

2) Strabismus + Orbit

-8 year old girl with hyperopic correction, attending with mom.Asked to examine eye movements.Duane’s type 1 with small left esophoria for near without specs.Orthophoric with specs.Asked management. Do nothing!

-60 year old female with TED. Asked to examine orbits,DO NOT examine eye movements. Faffed around palpating orbital rim and commenting on periorbital swelling and xanthelasma. Eventually decided that Hertel’s, Colour vision, red saturation and RAPD should be tested! Then a discussion around treatment options. Role of steroids, orbital decomp, radio Rx and  I 131.

3) Posterior segment

-Examine posterior segment of right eye. Silicone oil filled eye, no indentation. Macular scar with apparent traction from temporal periphery. Asked to describe, not asked. Possibly FEVR though

-Examine Posterior segment of BE. Vitelliform dystrophy Right- vitelliform stage Left- atrophic phase. Asked about making diagnosis and electrodiagnostics

-Examine posterior pole of BE. Discs slightly pale.At first glance appeared NAD pretty much. Asked to examine foveas closely, had a subtle grainy appearance with loss of foveal reflex. Told patient has very poor VA. Said might be early Stargardts or cone dystrophy. Discussed electrodiagnostics AGAIN

4) Glaucoma and lid

-Glaucoma drainage device with scarring of conjunctiva. Asked indications for tubes.

-Asked to examine and comment on a glaucomatous disc.Give important positive and negative findings. Asked about NTG and about field changes typical of NTG?Not aware of any relating to just NTG.

-Lash ptosis and entropion of upper lid-Asked questions regarding cicatricial causes of entropion. Discussion around SJS/TEN and OCP.How would I treat?

5 ) Cataract and anterior segment

-Right decompensated cornea, bullous keratopathy with BCL in situ. Had old large ECCE corneal incision. No guttatae in the other eye.Quietpseudophakia

-Right scleral tunnel phaco (looked recent) and Lasik flap scar.Discussion around Phaco post corneal refractive procedures and current formulae

-Right Fuchs heterochromiciridocyclitis. Had right phaco and trab.