Candidate 9 Location: Moorfields Eye Hospital, London
Date: Feb. 2000
OphthalmologyCase one
I was introduced to a woman in her thirties and asked to take a history. I noted that she was tall and suspected that she may have Marfan's syndrome. The history revealed that she had problems with her vision since teen and had retinal detachments operation.
The examiner then asked me to perform the necessary examination. I chose to examine the anterior segment on the slit-lamp which revealed bilateral lens subluxation with some nuclear sclerosis. I was asked about the other systemic manifestation of Marfan's syndrome and the various options of treating the lens problems.Case two
The next patient was a middle-aged man. The examiner told me that he had had a right penetrating eye injury and wanted me to examine the anterior segment.
He had a right band keratopathy and was pseudophakic. On the left eye I looked for evidence of sympathetic ophthalmia but there were none. Questions on the management of band keratopathy.Case three
Slit-lamp examination of a patient with left corneal graft. The patient also had left pseudophakia. The other eye was phakic but showed signs of Fuch's endothelial dystrophy and nuclear sclerosis. Questions on signs and management of corneal rejection. The other examiner asked how I would manage the other eye, I mentioned combined graft and cataract extraction and implant.Case four
Another slit-lamp examination. The patient had a right pseudo-exfoliation syndrome with trabeculectomy and cataract. Questions on the possible complication of cataract extraction in such patient.Case five
Slit-lamp examination of the corneal of a man in his twenties. He had bilateral horizontal Descemet's breaks but the corneal diameter in both eyes were normal. There were also scars on the temporal cornea near the limbus which I told the examiners were due to previous goniotomy.
Questions on the incidence, presentation and management of primary congenital glaucoma.Case six
Indirect ophthalmoscopy with a 78 D. The patient had an epiretinal membrane and sectorial pan-photocoagulation in the superotemporal region. I made a diagnosis of old branch retinal vein occlusion. The examiner wanted to know the results of Branch Retinal Vein Occlusion Study.
Medicine / Neurology
Case one
Neurological examination of the lower limbs of a young woman. There were some motor weakness in both legs with up-going plantars and hyper-reflexia pointing to upper motor neurone lesion. I was asked to give a differential diagnosis. I listed demyelination and possible spinal cord compression from lesions such as neurofibroma as the most likely diagnosis (in view of the patient's age).Case two
I was asked to take history from an elderly woman. She had right sudden visual loss suggestive of a vascular cause. Examination revealed right relative afferent pupillary reflex and a right optic atrophy. I mentioned that the main diagnosis is between arteritic or non-arteritic ischaemic optic neuropathy. This was followed by detailed questionings about the differences between the two including signs, symptoms and diagnosis.Case three
The next patient had a dysmorphic features with very short stature and hunched back. I was asked to examine her eyelids and she appeared to have a right Horner's syndrome. I was asked to look at her irises on the slit-lamp which revealed bilateral Lisch's nodules. Questions on the different types of neurofibromatosis and the ocular manifestations.Case four
Cranial nerve examination. The patient had bilateral facial weakness and also poor power of the tongue muscles. I gave a differential diagnosis of myasthenia gravis and oculopharyngeal muscle dystrophy. Questions on diagnosis of myasthenia gravis.Case five
I was asked to examine the ocular motility of a patient with double vision. He had a small exophoria in the distance during cover/uncover test. Ocular movement revealed absent up-gaze and poor vertical saccade. I asked for an opticokinetic drum so as to demonstrate convergence retraction syndrome but there wasn't any in the room. I then proceeded to demonstrate the presence of light-near dissociation. The examiner asked me the possible causes of Parinaud's syndrome.