Clinicl case interpretation:

1. A 13-year-old girl was brought to your clinic by her mother complaining of reduced vision. Visual acuities are 6/18 in both eyes, reading N8 unaided. Her parents have just been divorced. How would you manage this patient and what investigations may be appropiate?
(Don'tt forget non-organic visual loss beside organic causes in this age group and the relevant tests to differentiate between organic and non-organic causes.)

2. A 55-year-old man who works as an engineer has attended the eye clinic previously with latent angle closure glaucoma and has bilateral peripheral iridttomies performed. His refraction is +7.5DS in the right eye and +8.00DS in the left. On this occasion vision is reduced to 6/12 in each eye because of cataract. What potential risks would you perceive with this patient and how would you manage his cataract?

3. A 33-year-old woman has been awared of a degree of left sided proptosis for several months.she presents to your clinic with a one-week history of pain and redness in the left eye,reduced vision and an apparent corneal ulcer. Explain the possible causes of this patient's symptoms and how you woud manage her.

Viva:

Two examiners (one Indian and one British) for general medicine and neurology:

• While in the ward preparing for the next day list, you are called to attend a dibetic patient who just collapsed. What would you do? Call for help,  ABC, Test for glucose and  further examinations. Then one of them showed me a ECG with MI and heart block.
• Papillaedema and its management. Field defects of chiasmal lesion and implications of homonnymous hemianopia. Then the bell.

 A British and An Arabic examiner for pathology and surgery

• They show me a lot of photos: traumatic dislocated lens, post-trabeculectomy flat anterior chamber, capillary hemanigioma, Brown's syndrome, Morgagnian's cataract, molluscum contagiosum, epithelial downgrowth, combined surgery in hypermature catarect, surgery on inferior oblique muscle. Before more photos, the happy moment of the bell.

Ophthalmic medicine

• Optic atrophy in young, principle of OCT, heterochromia, Fuchs' heterochromic cyclitis, MRI for posterior scleritis, vitritis, diplopia work up, effect of herpes zoster on the eye, anisocoria and before more questions, the sweet sound of the bell.

Clinical examination
41 candidates from  one hundred passed and went on to the clinical examination we were divided into 6 groups I was in group (D ).  I was examined by 2 examiners: one Nigerian and the other Arabic. 

Case 1
Examine the right eye of a middle-aged lady with slit-lamp. She had a phakic IOL, 2 peripheral iridectomy in upper section closed with 3 interrupted sutures. I was asked why phakic IOL used? Examine the fundus with a 90D revealed a tesselated  fudus, myopic crescent. Asked why she didn't have LASIK and how to follow her up? I mentioned IOP, endothelial count and fundal examination. What is the risk of retinal detachment in pre- and post-operative period?

Case 2
Examine a nearly 6-month old beatiful girl with a right enucleated/eviscerated eye with granulation tissue and a mass behind the secured muscles. I was not sure if it is eviscerated with midpore implant for trauma or enucleated for tumour I mentioned both possibilities.
Q: What tumor do you have in mind? A: Retinoblastoma.
Q: What is this tissue? A: I don'tt know Sir
Q: What do you usually do when you are uncertain of a tissue? A: Biopsy and sent for histopathological.
Q: Ok, this is a case of  recurrent retinoblastoma, what will you do for the other eye?dilated fundus examination with scleral indentation.Q:what will you do if there is small mass at periphery?U/S & refer to ophthalmic oncologist if it small:laser-cryo-RX
If there is recurrent in the biopsy of the enucleated eye..chemotherapy

Case 3
Examine the right eye of a 6-year-old boy with a slit-lamp.
There was a paracentral corneal opacity with 2 corneal stitches and an anterior chamber IOL. The corneal incision would was closed with interrupted 10/0 nylon with presence of  peripheral anterior syneachia.
Q: What is the likely scenario? A: Trauma to the eye resulting in globe rupture, lens injury which developed into traumatic cataract. The patient underwent repair with cataract extraction and primary IOL implant. (He told me that might be a secondary implant and I agreed.)
Q: What do you expect the vision to be? A: There is good vision potential unless there were posterior segment complications but it was likely to be lower than the fellow eye and when compared to his previous vision.
Q: What would be your instructions to parents regarding the other eye? A: Occlusion. (Come to think of it, the parents need to contact the ophthalmologist if the good eye become blurred or red due to the risk of sympathetic ophthalmia)
Q: How often would you perform the patching? A: Till the patient is around 8-year-old (Also asked about how many times or hours per day and I mentioned 3 hours/day
)
Case 4
Inspect a young male in his mid-20s. 
The examiner told me the patient was deaf; I found muscle twitches in the face and the patient squeezed his eyes during examination. There was a jerky nystagmus and I described it with using the mnemonic DWARF. The left eye had a band keratopathy.
Q: When do you think the band keratopathy occur? A: Early in life when he was about  2-year-old because of the prescence of nystagmus.
Q: What about these twitches you see? A: (That was a difficult question for me) Myokaemia? (The examiner tried to guide to guide me but I was clueless then he said it was hemifacial spasm.)
Q: What will you do for his facial problem? A: Refer to a neurologist. (He agreed but asked what drugs the neurologist will give him? I thought a little bit and said carbamazepine but I wasn't sure. Eventually it got to botox injection what was the answer he was after).

Case 5
Examine the fundus of a 17-year-old boy with an indirect ophthalmoscope.
The lens was 28 D  which was not the usual 20D that I used but there was not much difficulty. I described my findings and said it was retinitis pigmentosa. He told me the central vision was poor and what would I expect to find? I said there might be macular involvement but I need to confirm this with the indirect ophthalmoscopy using 78 or 90D lens.He asked if RP patients are more prompt to glaucoma, I said yes and he asked me to examine the optic disc again and this time I found the disc was cup with glaucomatous characteristics.

Case 6
Examination of an old woman using indirect ophthalmoscope.
It was difficult to examine as there was a nasal shift of blood vesseles. With some problems, I found hard exudate in the macula and mentioned diabetic retinopathy. He asked me if I would like to examine for other signs using a direct ophthalmoscope. I mentioned the retina thickness then promptly regreted it and quickly corrected myself by saying that I would need special filters such as the red free on the slit-lamp to do so. He went on to talk about clinically significant diabetic maculopathy and the indications for laser and fluorescein angiography.

Case 7
Examine an old man using an indirect ophthalmoscopy.
I focused on the anterior segment and he was pseudophakic. There was a fibrous band along the arcades with a hypereamic disc. The view was not great. I was asked what this was? I described my findings and believed it was a proliferative diabetic retinopathy. He asked about pan-photocoagulation and asked if vitrectomy was indicated? I said no as there was no macular detachment or band crossing the macula.

Case 8
In the last 5 minutes I was asked to examine a 3-year-old child. She was esotropic with an abnormal head posture. I placed the head in the normal position first and carried out cover /uncover and ocular motility but she was uncoperative or tired for a smooth examination. I was asked about the findings. I mentioned esotropia, latent nystagmus and inferior oblique over-action in the right eye.  He asked me if there was anything else and I said I have nothing else to add as I could not see any other signs.

I didn't know how I did and have to wait for about 3 hours. That was the longest and the most difficult time in my life but once again THANKS to ALLAH, I passed, my email is dr_ma1973@yahoo.com.