Communication station

Ms Thomas, Year 3 university student presented to casualty with sudden LE blurring vision of 2 days onset with brow ache. VA RE 6/6, LE 6/60. When checked with trial lenses, noted LE VA can be improved to 6/6 but RE became 6/60.
Anterior segment and fundus look normal in both eyes. No RAPD and pupil were equally reactive.
Instruction to take a history from this patient and advise her accordingly on the further investigation that needs to be taken.
* During history, it was noted she had an aunt who had recently diagnosed with brain tumor and passed away 4 years ago. She’s concern of similar problem due to her headache and vision impairment.

Investigation station:
Hess chart showing Left eye adduction deficit (Straight line vertically down passing through the center) and the center square was contracted and deviated temporally. There is secondary RE abduction overaction temporally.
Discuss possible diagnosis. Talked about muscle restriction, trauma, possible 3rd nerve palsy and finally talked about myasthenia gravis. Examiner enquire what further history I like to ask.
The examiner volunteered the finding of nystagmus on the left eye on abduction. Diagnosis confirm left internuclear ophthalmoplegia. Then showed a MRI scan with small hyper intense lesion at the 4th ventricle. Discussed on the further management for suspected multiple sclerosis including referral to neurologist and lumbar puncture for risk stratification.

Patient management 1:
Scenario 36 week old baby screening for ROP. Fundus appearance Stage 2 zone 1 with plus disease. Discussed on indication for treatment, choice of treatment, both short term and long term complication of Laser ablation. Discussed on role of anti-VEGF for treatment of ROP. Then discussed on college guideline on screening and treatment criteria for ROP.

Patient management 2
Given a case of 75 year old patient with 6/9 vision BE referred from optician for cataract operation because he has difficulty driving. Noted IOP BE 30mmHg. Discuss what further history is needed.
Examiner volunteered that he has pseudo exfoliative material noted at the pupil margin with PSCC in both eyes. Discuss on how to proceed with cataract operation and manage of his pressure. Talked about zonular weakness, small pupil, patient counselling and need to bring down IOP before surgery. To do VF after the cataract operation.
Discuss on causes of raised IOP post cataract op, whether AC deep or shallow.

Ethics.
Cataract surgical check pre op.
Patient check pre op
College guideline on cataract ot staffing
If the surgeon noticed the lens with wrong power (10diopter difference) was given prior to inserting into the eye, what should be done?

Health promotion & Evidence based medicine.
Talked about the management of recurrent stromal keratitis. Discussed on the finding of HEDS study
Asked about Crutzfeld Jacod disease and its management.
How to prevent it in OT? IF one patient in the cataract list was suspected to harbor this organism, what should be done?
College guideline on crutzfeld Jacob disease

CLINICAL

Station 1 Anterior Segment
1) Slitlamp exam RE was phakic but appear normal except some epithelial irregularity on the inferior paracentral cornea perhaps due to dry eyes. LE noted full thickness graft with all sutures removed. minimal vascularisation of the graft but otherwise graft is clear with no evidence of rejection or failure. Noted LE pseudophakic (PCIOL) with ECCE scar. I suggested possibility of psedophakic bullous keratopathy post complicated cataract operation needing cornea graft. However, examiner explaind patient had graft before cataract operation. discussed on indication for penetrating keratoplasty which included keratoconus. I was not allowed to re check the right eye but I said it was possible and we discussed all cornea feature of keratoconus and how to diagnosed early keratoconus with retinoscope and topography. Discussion went to how to manage cataract in a eye with cornea graft.

2) Patient has iris clip lens with a PI on the RE. Left eye is phakic. Discussed on indication, pros and cons for putting and iris clip lens as well as its complication. Examiner asked for a specific difficulty with iris clip lens, which I mentioned requires sufficient iris tissue to be caught by the clip to prevent post op dislocation. Examiner seems happy with the explanation. Also mentioned difficulty with pupil dilation using this lens and may affect fundus examination like in a patient with diabetes.
3) Sorry, can’t remember.
 

Station 2 Glaucoma and Lid
1) Slit-lamp examination noted LE with a bleb which was diffuse, white, not cystic nor inject. Presence of releasable suture on the cornea and conjunctival suture as well. No other underlying secondary cause for glaucoma can be seen. We discussed treatment strategy for COAG, medication -> laser SLT -> trab with or mitomycin / 5FU -> tube vs ciliary body procedure such as cyclodiode and ECP (endoscopic cyclodiode photocoagulation).

2) I was given a brief history that patient has on and off blurring of vision in the evening. Sliplamp examination noted shallow AC with van herrick technique and presence of peripheral iridotomy demonstrated with retroillumination. Optic disc cup disc ratio was enlarged. 0.8 in the RE and 0.7 in the LE. Explained the technique of examination of the disc in glaucoma (5R) and explained that this patient probably have repeated acute angle closure attack when it gets dark due to pupillary dilatation. Repeated attacks led to optic disc damage. Examiner gave another scenario that this patient IOP was initially under controlled with eyedrops after the laser PI few years ago but lately the pressure has gone back up to around 25mmHg. I suggested cataract is the culprit as the lens thicken, the angle becomes even narrower leading to poor drainage. Treatment is to remove the cataract. Examiner happy with explanation.

3) A patient with lower lid pearly raised nodule with subcutaneous infiltration and a scar. Discussed on differential diagnosis of BCC, squamous cell ca and sebaceous cell ca. Discuss on treatment option including MOHs micrographic wide excision, conventional wide excision with frozen section control, full thickness lid pentagon excision. Discussed on newer modality of treatment for BCC including use of cryotherapy, PDT, 5FU cream and Imiquimod cream.

Station 3 Posterior Segment
1) BIO examination of the fundus. Noted cryo scar at the temporal peripheral retina 3-5 o clock and supero nasal quadrant. Otherwise fundus looks normal and flat. No break noted. Patient is pseudophakic. Discussed on possible cause of cryo scar. Mainly on pseudophakic RD and its management.

2) Slitlamp 90 D examination of the showing PRP scars with no evidence of neovascularization or VH. Noted macula is flat with some DH and BH but no exudate. Discussed on most possible diagnosis, which is PDR and the reason for PRP as well as its complication. Discussed on management of Post laser CMO.

3) Slit lamp 90D examination showed macula thickened irregular border and surface measuring 1.5 disc diameter involving the fovea. No evidence of drusen or hemorrhage. Not allowed to look at the other fundus. Examiner did not wait for me to start discussing on possible diagnosis but immediately told me that the patient had wet ARMD. Discussed on management issue of wet ARMD: NICE criteria for starting anti-VEGF therapy. Discussed on the option of using ranibizumab vs aflibercept. (aflibercept is preferable because of 2 monthly dosing after the initial 3 doses)


Station 4 Strabismus and orbit
1) Examiner explained that patient had consecutive exotropia following surgical treatment for esotropia several years ago. She had a second surgery done to correct that problem. Her left eye is amblyopic and she wears contact lens on the right eye. I was told to do cover test. Noted LE esotropia worse for distance than near. Initially I offered patient LE LR recession but examiner told me IF patient have 40 prism diopter, to discuss on other options. I offered conservative treatment in view of repeated operation been done by using prism if necessary although LE is amblyopic. Then I suggested referral to strabismus expert in view that patient wanted better cosmesis. The options for patient I suggested was either RE recess and resect or by using Botox. Examiner satisfied upon mentioning botox.

2) Observe patient with bilateral upper and lower lid retraction. Examiner did not allow me to continue the routine orbit examination, just asking me to demonstrate how to examine for proptosis. I offered to examine from behind and lateral but he wanted me to show him how to use the HERTEL exophthalmometer and the proper way of documenting the finding. Noted patient lateral canthal width of 120mm and both cornea measure 26mm, confirming presence of proptosis. No further physical examination on the patient. Exhaustive discussion on diagnosis of thyroid eye disease, especially sight threatening thyroid eye disease. Role of IV steroid, surgical orbital decompression and radiotherapy for treatment. I stressed the benefit of medical and surgical decompression and discussed on the risk of radiotherapy. However, forgot to mention that radiotherapy needs several weeks to be effective and therefore not suitable to be used in sight threatening cases.

3) Extraocular movement showed LE Brown syndrome in an adult. Discussed on management issue, conservative, prism vs surgical correction.

Station 5 Neuro-Ophthalmology
1) Pupil examination. Noted direct light reflex was absent on the RE but no reverse RAPD. Diagnosis of Adie’s pupil. Discussed differential diagnosis of small pupil and anisocoria worse in the dark, which is Horner syndrome. Discussed on how to confirm horner phrmacologically.

2) Confrontation visual field with Left Homonymous hemianopia. Examiner did not wait for me to check on macula sparing. Discussed possible location of the pathology based on congruity of the field defect: post chiasmal, either pre or post geniculate body. Examiner gave a scenario that the patient presented with an acute left hemiparesis but no visual complaint. Only noted homonymous hemianopia on examination. I concluded the lesion near the right internal capsule. Discussion on management of acute haemorrhaging vs embolic stroke. Treatment of using rTPA was suggested apart from aspirin and examiner was satisfied.

3) I was asked to take a brief history from patient: Sudden horizontal diplopia of variable onset and severity. Usually worse towards the evening but not always. No ptosis. Extraocular examination appear full although patient complained of mild diplopia on left gaze. Saccade appear normal. I should have done cover test to determine presence of esotropia distance worse than near to confirm the presence of 6th nerve palsy. Instead wasted too much time determining fatiguability, cogan twitch for MG. Diagnosis: very subtle or resolving 6th nerve palsy.
 

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