1st Day : Clinical case interpretation

1. 75 year old woman has been attending the clinic for some time with an indolent left corneal ulcer. There is a history of joint pains and weight loss, and she has dry eyes. She presents acutely with worsening pain in her left eye and blurring of vision .on exam u notice the ulcer has perforated with flat AC. 
Describe acute and long term management and  what investigations are appropriate.

Answer: DD should include causes of resistant ulcer with dry eye and collagen diseases, infective keratitis, and work up: for perforated ulcer, including team work with rheumatologist, and long term ttt of dry eye with attention to other eye.
 

2. A 3 years old boy has been seen at the clinic for 2 years with bil. Watering & has had 2 probing procedure performed. On both occasions the probe was passed easily. The Rt. Eye has settled but on the left side he is having recurrent dacryocystitis every few months requiring systemic antibiotics. His parents are angry and are demanding something is done or a second opinion is given. Explain how you would manage this situation & write a letter to the GP detailing your action.

Answer : The action is straightforward. I mentioned the surgical options includ either intubation or DCR after work up for epiphora, but the important point in the question is how to deal with the parental concern.

3. A 50 year old male artist in known to have small bilateral inferior retinoschisis. He presents to his optician having become aware of some distortion in his right eye with a change in color perception. The optician thinks the retinoschisis has enlarged on the right side and is now encroaching onto the macular area. The patient is referred for your opinion. What is your differential diagnosis, and how to investigate and manage him?

Answer: The main part of the answers should be the differences between retinoschisis and retinal detachment: relative versus absolute visual defect, presence of holes and pigmentations, effects of focal laser on the retina between the two conditions. Finally the treatment options. Other differential diagnosis include optic neuropathy, macular disease, and other causes of visual distortion. 
 

2nd Day: Viva

General medicine &Neurology 
(An English Ophthalmologist and an Indian Physician)

The English Examiner:

• A laptop picture of bilateral proptosis with lid retraction. The patient also had heat intolerance.  I diagnosed thyroid eye diseases and was asked about the other ocular features of thyrotoxicosis: optic neuropathy, corneal exposure, and restrictive moypathy and lid signs. I was also asked about the systemic signs and symptoms: tremors, weight loss, diarrhea, muscle weakness, nervousness, and atrial fibrillation.

 
• Asked to look at the visual field of a 52 old-lady. The field indices showed it was reliable. It was a 24-2 SITA, there was a right absolute upper altitudinal scotoma so I gave a differential diagnosis which include:  ischemic optic neuropathy lower branch a. occlusion or branch retinal occlusion. Asked about the typical features of giant cell arteritis and I mentioned if if she is 70 years old with difficult mastication I would consider giant cell arteritis with arteritic anterior ischaemic optic neuropathy.  Questions on management,  the reliability of ESR, C-reactive protein. How to give steroid and the preliminary investigations before the steroid was given. Also about pulse steroid therapy. Temporal artery biopsy, how long after steroid institution will the histology be negative and what to do if biopsy is normal? Would I do the other side if the result is normal? How to monitor the patient's progress?.

 
• What is benign intracranial pressure? I mentioned bilateral palloedema with normal brain imaging and normal CSF analysis. I also said high opening pressure by lumber puncture and was asked what is the normal values?  I mentioned less than 20cm H₂O and 25 in obese patients. Asked how to manage the patient? I said this should be managed jointly between the ophthalmologist and the neurologist. Options include: Conservative: weight loss ,stop drug if patient is on any that are associated with BIP, follow up for headache severity and regular visual field testing. Medical management include acetazolamide and if this failed surgical treatment such as shunt for persistant raised pressure with disabling headache and optic nerve fenestration if there is progressive visual loss. 

The Indian examiner
 

• What are the ocular complications of rhematoid arthritis (RA)? Dry eye, scleritis, episcleritis, preph.corneal ulcer, corneal melting. What is the treatment for RA? , NSAID, hydroxychloroquene, steroids. How about antimetabolites? Methotrexate and azathioprine. Asked which is better chloroquine or hydroxychloroquine? I mentioned hydroxychloroquine is better as it has less retinal toxicity.  What is the toxic dose of hydroxychloroquine? 6.5 mg/kg/day of hydroxychloroquine and 3mg/kg/day for chloroquine for 5 years.  What are the other arthropthies affecting the eyes? Ankylosing spondylitis, SLE, juvenile rheumatoid arthritis, sarcidosis. How to differentiate between RA and SLE? Clinically SLE does not usually cause joint deformities, there are malar flushes,  more severe systemic complication such as renal failure, lung desease and cardiomoypathy.  Laboratory test is positive for anti-DNA antibodies in SLE. 

 
• During fluorescence angiography, a patient experienced tachycardia and difficulty with breathing. How would you manage the situation? I will consider possible anaphylatic shock. The action to take include stopping the injection, assessing ABC, shouting  for help. Give 100% O₂ mask, give 0.5 mg adrenaline im which can be repeated after 5 minutes.  10 mg iv chlorpheneramine, 200 mg hydrocortisone, saline intravenous. How about if the patient fails to improve? Call for help again, give nebulized bronchodilators such as salbutamol. If still not improvement? Refer to icu for intubation and mechanical ventilation.

 
• What are the side effects of steroids? How do you diagnose osteoporosis? Clinically bone and joint pain, bone scan will show decreased bone density and T score of DXA is below -2.5.

Ophthalmic Surgery & Pathology
(2 Indian Examiners)

First examiner

• What is granuloma? Chronic inflammatory reaction with predominance of macrophages which may aggregate to form giant cells and lymphocytes what are the Types of giant cells? How can u differentiate bet.them? Examples of granulomas affecting the eye and there giant cell types?

 
• What is pannus? Fibrovascular ingrowth Which layer of the cornea does it affect? Sub epithelial Examples of diseases that cause pannus? Trachoma, contact lens SLK, rosacea.

 
• A laptop picture of anterior staphyloma. Define staphyloma? Protrusion of outer coat of which become lined by uveal tissue Causes? congential,  inflammation, angle anomaly.

 
• A picture of Lester Jones tube. What is it made of? Silicone and no glass. Indications? Obstruction of canaliculi. How can you control bleeding during DCR? I classified them as pre, intra, and post-operative measures then mentioned them in details.

 
• A scenario of a patient hitten by a squash or a tennis ball what each ball may cause? If presents with diplopia how would u manage? 1st I will exclude globe rupture, retrbulbar hge, globe is free I will suspect fracture of the floor.  Investigations? Assess ocular motility, sensation along infraorbital nerve., and CT how would u order the CT? Coronal section with 2mm cuts.

Second Examiner 

• What type of cataract surgery do you do? ECCE. What type of suture do you use? Nylon 10/0. What are the other types of sutures used in ophthalmology? Uses of vicryl? How can you  manage slipped muscle in squint surgery? Follow its sheath, avoid turning the globe to other side, beware of oculocardiac reflex.  Other complications of squint surgery and their management? Perforation, malignant hyperthermia from anaesthesia.

 
• A scenario of an infant 3 months old with bilateral dense cataracts. How do you manage? Assess the general condition, systemic associations, exclude secondary causes, do the 2 eyes within 2 weeks.  Steps of surgery in details? General anaethesia, anterior chamber maintainer,  scleral tunnel, anterior capsulotomy using a vitrous cutter, irrigation and aspiration, post capsulotmy, anterior vitrectomy. How do you do IOL calculation in infants? Less by 20% before 2 years and 10% between 2-8 years. Why? To accommodate for myopic shift as the globe grows. When to implant? After 1.5 years.

 
• An FFA showing a full thickness macular hole. Grades of macular hole? Incidence in the other eye? Management? What is the most important single step during surgery? ILM peeling. How can you identify the ILM? Stained by trypan blue, ICG or fluorescence. 

 
• The examiner draw a right fundus with an upper temporal RD? Where would you expect the tear? At1 o’clock using Linscoff's rule. Management? This is an emergency as the macula is not involved. Gas, scleral buckle, or primary vitrectomy and saved by the bell. 

Medical Ophthalmology
(An Indian and an English examiner)

The Indian examiner

• A picture of ring corneal infiltration with feathery appearance and satellite lesions manage? I mentioned infective keratitis and would like to take a history to learn about trauma involving organic matters and contact lens wear. What is your differential diagnosis:  fungal, bacterial or acanthmeoba?  How to confirm it? Asked about Gram and Giemsa stains, blood agar,chocolate agar, thioglycolate broth,and Sabouraud media and non-nutrient agar enriched with E.choli.  How long  does it take for fungal to grow? 2weeks. How to confirm early? By stain with Giemsa stain,KOH ,and direct view of hyphae by confocal microscopy or even PCR.

 
• Fundus picture: severe neovascularization at the optic disc (NVD) and elsewhere (NVE).  I will regard this as an medical emergency and will arrange for immediate PRP what are the complications of PRP? I mentioned short and long term complications.

 
• A picture of bilateral mild upper eyelid retraction.  I suspected TED. What other manifestations of TED? Soft tissue infiltration ,corneal exposure, optic neuropathy, restrictive myopathy, what is the cause of lid lag fibrosis of levator. 

 
• Another picture of right hypotropia with upper lid lag.  I gave a differential diagnosis of TED,  orbital floor fracture, limited elevation double elevator palsy, IR fibrosis or entrapment, brown syndrome.  How to differentiate double elevator palsy and TED lid lag?  Forced duction test how to treat IR fibrosis in TED.  After the condition become stable for at least 6 months and there is diplopia in primary position or reading position.  If there is significant proptosis, orbital decompression to be done first  if needed before inferior rectus recession usingadjustable suture.

 
• A picture of anterior segment with PXS.  What are the ocular manifestations? Angle pigmentation,  high IOP, weak zonule, poor pupil dilatation. What would you like to examine? The angle, IOP, fundus, visual field. Then he gave me fundal picture of the patient optic disc with  C/D 0.8 so it is most probably glaucomatous.

2nd Examiner

• A picture  of closed punctum what are the possible causes? Congenital obstruction, inflammation, infection. 

 
• A picture of small inferotemporal  pigmented conjunctival lesion told that the complaint is dimined vision.  I noticed a sectorial hyperpigment of the iris so I suspected intraocular tumor with sclera invasion. Good! How can you confirm it? Fundal examination, U/S, UBM then he gave the U/S picture with some colours in it.  I told him that I am not familiar with coloured ultrasound but I think it shows Doppler U/S with a highly vascular homogenous mass. Good! 

 
• A picture of an old man with left proptosis and dystopia complaining of double vision.  I gave a DD of proptosis using the mnemonic VEIN (Vascular, Endocrine, Inflammatory and Neoplastic)  how to manage VA, pupil, measure degree of proptosis, corneal sensation, ocular motility, optic nerve functions, fundal examination.

 
• A picture of giant papillary conjunctivitis (cobbled stone). I mentioned it may be VKC or contact lens related. How to manage VKC.  Take history for severity,  recurrence of attacks examine the eye for corneal ulcer or complication of previous treatment, then I will begin treatment with topical mast cell stabilizer such as sodium cromoglycate and anti histaminic then topical steroids how to treat shield ulcer debride mucous, therapeutic contact lens and steroids. 

 
• A picture of severe purulent conj. Discharge I suspect gonococal infection…the bell went.

3rd Day: Clinical exam
(An Indian and an English examiner)

Case 1: 
The Indian examiner asked me to examine the adnexae of a young lady. There was mild right ptosis and some mild lid twitches when she talks and mild lid retraction of the left side.  Asked why the other eye has lid retraction? Hering's Law.  I  measured the ptosis and tested the eyes for Bell's phenomenon. While lifting the ptotic lid the retraction of the contralateral lid disappeared. Ocular motility was normal. Testing jaw movement brought out the winking thus confirming  Marcus- Gunn jaw winking ptosis.  Asked about treatment? Bilateral levator recession followed by brow suspension to abolish the winking and achieve symmetry.

Case 2: 
The English examiner asked me to examine the right anterior segment of an old lady.  There was ECCE with in the bag IOL and mild PCO noticed only with retro-illumination.  The wound was closed with continuous 10/0 nylon sutures. When I mentioned these findings he asked me to examine her posterior segment with a 90D lens? There was a macular hole and drusen.  He asked me to examine the left posterior segment? There was a retinal detachment with a grade C circumferential PVR.

Case 3: 
The Indian examiner asked me to examine the anterior segment af an old lady. There was diffuse corneal edema, up-drawing pupil due vitreous in the anterior chamber and a decentered PCIOL. Asked about the causes of oedema? Fuchs' dystrophy, complicated surgery or vitreous wick syndrome.

Case 4: 
The English examiner asked me to examine a middle age man using an indirect ophthalmoscope? There were bilateral chorioretinal coloboma involving the posterior poles and extending inferonasally. There were also bilateral  inferonasal iris coloboma.  Questions on possible systemic and ocular associations?. 

Case 5: 
The Indian examiner asked me to perform cover/uncover test on a young man? The left vision was poor for distance with and without glasses, so I did the test only for near . There was a left exotropia. Then asked to examine the primary and secondary angle of deviation? There were apparently equal. Then moved on to examine the ocular motility and found to be normal.

Case 6: 
The English examiner asked me to examine an old lady using a 90D lens. There was a right  clinically significant macular oedema due to diabetes mellitus.  Then I was asked tto examine her using the binocular indirect 20D! There waere bilateral myopic changes with right moderate NPDR +CSME and left ,ild NPDR with scattered laser marks. Questions on the management of CSME?

Case 7: 
The Indian examiner asked me to examine a 5 years old girl using a torch? There was bilateral severe corneal opacities and vascularisation and  the left had anterior staphyloma. Questions on possible causes? I mentioned congenital (corneal dystropy, congenital glaucoma) or acquired (infections, vitamin A deficiency, trauma, inflammatory). The examiner was not satisfied but the bell saved me !!!!!!!!!!!!!!!!!.

The results were announced 3 hours after the clinical examination which were the most stressful 3 hours of my life but the ending was a HAPPY one! 

I am happy to help any colleague of mine with this examination and  my e-mail is: mraslan75@gmail.com