A 60 year-old woman with bilateral myopia of -8.00D and cataract. Explain to her how you will carry out the operation ie. local or general anaesthesia and the choice of implant for the operation. 
(Suggestion:  Ascertain if the patient wishes to have operation. Explain how the new lens may affect the vision, whether the patient prefer to maintain the same refraction or wishes for emmetropia. Is she happy with local anaesthetic and if not is there any contraindications to general anaesthesia?) 
 

Scenario 2: (Appearing in Sept, 2003) 

You are given a referral letter from a GP about a 23 year-old footballer with an unilateral red eye. The patient has been treated with chloramphenicol eyedrop without improvment. You are asked to ask the patients some questions and decide on the appropriate treatment. 
(The patient turned out to have Reiter's syndrome. The candidate did not ask about the sexual history and systemic enquiry regarding backache etc as expected by the examiner. In addition, the examiner expected the candidate to inform the patient the effect of mydriatic on his football career.) 
 

Scenario 3: 

A 50 year-old man with bilateral advanced glaucoma has just failed his Estermann visual field and you have to tell him that he should not be driving. 
(Suggestion:  Explain the finding to the patient. You may say something like ' We have performed a special test called Estermann test because of your glaucoma. Do you know why we carry out this test?' Find out the patient's need to drive. Is there any support at home?) 
 

Scenario 4: 

A 40 year-old woman with a choroidal mass returns for her investigation. The chest X-ray suggests the presence of metastatic carcinoma. 
(Suggestion:  Verify that the chest X-ray belongs to the patient and let the patient ask the questions for example ' We have been doing some investigations since we discover a lesion within your eye. Do you know why we are doing the investigations?' find out the expectation of the patients then say 'The results of the chest X-ray have come back and there are something showing on the film' or alternatively you can say ' I am afraid we have bad news for you' and the patient will likely to say 'Is it cancer?'. This will be better than come out with sentence like ' You have cancer!') 
 

Scenario 5: 

A 50 year-old man with a painful right blind eye. Advise regarding the various options for treating his painful eye including enucleation or evisceration. 
(Suggestion: 
Ascertain the severity of the pain and the patient's desire of keeping an intact globe. If enucleation is contemplated, consider the need for  AE)

Scenario 6: 

A 63 year-old man returns 4 weeks later for a follow up cataract visit. Refraction shows that a wrong lens has been inserted resulting in a hypermetropic shift. The patient is unhappy that he could neither read or see distance without glasses. Explain to him what has happened and the various options open to him including lens exchange and contact lenses. 
(Suggestion: 
Find out how inconvenience it is for the patient. Whether the patient was hypermetropic before the operation and what he had been told about the final refraction prior to the operation? Explain the varioius options open to him.) 
 

Scenario 7: 

A 35 year-old has had two failed corneal graft for heretic corneal disease. The cornea is heavily vascularized. He likes to have another corneal graft but you know there is little of a successful outcome. Explain to him why you think a re-graft is not appropriate. 
(Suggestion: 
Find out why the patient wants a re-graft and his understanding about the success rate. Is he concerned about the cosmetic effect of a leucoma? In which case cosmetic contact lens may be useful.) 
 

Scenario 8: 

A 69 year-old woman is referred by her GP for possible cataract operation because of very poor vision in both eyes. After examining the patients, you discover that she has minimal cataract and the poor vision is caused by bilateral disciform macular degeneration. Explain to the patient why you think that cataract is inappropriate. 
(Suggestion: 
Explain to the patient what the problem is and why cataract extraction is unhelpful. Use the analogy of a camera to describe the eye for example: ' The lens of a camera is similar to the lens of your eye and the film within the camera is similar to the back of your eye. When the lens is damaged we can replace it with a new one which is similar to a cataract operation. However, if the film is scratchy, changing the lens may not alter the image captured on the camera. The problem you have is similar to a scratchy film so cataract operation will not improve your vision.' If there is a model of the eye present, use it to illustrate her problem. Suggest blind registration or partial sighted registration and low visual aids.) 
 

Scenario 9:

A woman has a 2 year old child with bilateral retinoblastoma. She is planning a second pregnancy and likes to know the risk of a having another child with retinoblastoma. 
(Suggestion: 
Find out how much the patient knows about the conditions and the inherited patterns. Is her partner aware of her desire of having a second child? Is it possible for the partner to be present during the consultation?) 
 

Scenario 10: 

You are the only doctor in the minor operating room and the eye unit. A woman is referred directly to you by her GP for a cyst removal from the right upper lid. However, the lesion appears to be a large basal cell carcinoma. You have no experience of excisional biopsy in this area. Explain to the patient why you are not going to carry out the operation on that day. 
(Suggestion: Find out how much the woman has been told about the lesion. Explain to her your concern and the need for her to be seen by somebody senior. Apologize for the inconvenience cause and arrange an early appointment for consultation.) 
 

Scenario 11: 

A 60 year-old man was diagnosed with glaucoma 3 months ago. He was given a beta-blocker to be applied topically twice a day. However, the intraocular pressures remains high and there is deterioration of the visual field. His wife says he is not taking the medication regularly. Find out if he has been taking the medications regularly and explain to him the importance of taking the glaucoma medication. 
(Suggestion: Drug non-compliance is a common problem. Avoid confronting the patient as the patient may deny it. Instead begin by asking if he has had problems with the eye-drops such as breathlessness and any problems applying them such as rheumatoid hands. Then explain to him the deterioration of the visual field and the risk of blindness and losing his driving license. Mention the alternative such as latanoprost or trabeculectomy.) 
 

Scenario 12: 

Consent for ptosis- patient wants general anaesthesia, you have to explain the advantages of local anaesthesia. 
 

Scenario 13: 
32 year old lady.  Seen by GP 4 days ago for right red eye.  Seen casualty 2 days ago by “new” SHO who thought it was uveitis with raised pressure, gave her dexamethasone 2hrly, levobunolol and cyclopentolate.  Now being seen by you in clinic. 
Take history.  Essentially what transpires is that the right eye is not getting better, the vision is poor and she is very upset.  She is angry that seemingly the SHO who saw her was uncaring and rude.  She intends to make a formal complaint.  In terms of past history she is asthmatic and says that since starting the drops, she has been feeling more SOB.  On closer questioning she also mentions the right eye being red and sore about 16 years ago. 
Read the rest of the “vignette”.  In fact the patient has a large dendritic ulcer, cells +2 in the AC but the IOP is normal.  There is also evidence of a corneal scar, probably old. 
Basically, you had to explain the problem, the need to change the treatment i.e. stop beta blocker because of SOB, decrease steroids because it was herpetic and need for antiviral agents, I mentioned both topical and oral will be given to her. 
I explored her anger a bit more, mentioned that it was difficult for me to pass judgement on the SHO, mentioned that he was new and that her concerns will be discussed fully with the said SHO.  Also said that sometimes it can be difficult to know its herpes simplex at initial presentation and the important thing is that we now knew what were dealing with and could treat it to the best of our abilities.  She seemed to be satisfied and “acted” less agitated.  Then she asked about time off work, she was anxious not to be absent if possible.  Told her there was no absolute contraindication to going back to work as long as it would not affect her taking the treatment.  But if she is feeling rough and we need to see her again anyway in 2-3 days time, then she might consider taking a couple of days off.  The decision was hers. 
 

Scenario 14: 

Glaucoma with extensive defect, asked to advise on stopping driving (she went on talking for 15 minutes).DVLA tell woman not to drive, patient insistent on continuing 
young nurse working in ICU with first onset of homonymous photopsias. related to migranous type symptoms. first half of station for 7 minutes - asked to take history - exclude other causes of flashes, then tried to subtype the headache. asked for precipitating causes, history to suggestive more sinister causes of headache, social history, family history, medication history and past medical history. was then asked by the examiners to summarise my findings, and give appropriate list of differentials. examiners then told me examination was entirely normal and consistent with my top differential of migranous headaches. second half of station for 6 minutes - asked to counsel the patient. told her about symptoms to watch out for, when to come back. how to manage and avoid headaches, counselling about driving, and most importantly asked her what she was most concerned about! 
 

Scenario 15: 

Take history from and consent patient with involutional ptosis. Patient wanted a consultant to operate on her and requested a GA. I had to talk her out of both
Scenario 16: 
Take a history from a diabetic who has presented with sudden loss of vision ( had vitreous haemorrhage).Obtain informed consent for PRP 
 

Scenario 16:
Age-related macular degeneration, consent for FFA, tell patient it is not amenable to treatment.Counselling a 50 year old librarian for cataract surgery. The patient is myopic with refraction of RE -15.00D (operating eye) and LE -14D (6/9). Biometry aim to leave at -3.00D. Questions asked by examiners: 
What would be her risk for retinal detachment? 
Questions asked by patient: 
•  Can she be left to wear glasses in the distance but read unaided? 
•  Why does she need to have the other eye done despite the good vision? 
•  Discussion on anisometropia. 
•  Can she have a general anaesthesia as she is scared or sedation? 
 

Scenario 17: 

28 year old professional footballer with low back pain and red painful eye. Asked to take a history and discuss management. Had to take his sexual history! 
 

Scenario 18: 

You are an SHO in the preassessment clinic for cataract surgery.The patient is a myope with prescription of -8.00 D  and -14.00D  and has been listed for a left cataract surgery with a post op refraction aim of -3.00D. Counsel the patients about the risks and benefits of the cataract surgery and the need to leave her a bit short sighted , need for a second cararact surgery soon.
 

Scenario 19: 

Woman 55 had “bleed” in the eye 2 years ago and also complained of visual obscurations lasting 30 mins. This was uniocular. On further questioning had visual auras like “shimmering lights” 
Asked for headaches – no headaches 
Asked for BP and DM and IHD and palpitations – history of BP and mild IHD andpalpitations. 
Bleeding in eye sounded like a vein occlusion 
Examiner wanted to know what I thought of the problems were and what I would do in clinic. Mentioned that I would like to clarify the bleed – then told me it was BRVO and VA was 6/9. Mentioned that sounds like migraine but also due to PMH would like to examine carotids and CVS to exclude emboli. 
Asked for features in history that would support either differential. 
30 mins was too long for embolic disease and auras are not typical – more like migraine. But in view of history I said that carotids had to be examined. Examiner wanted to know if it was really necessary to scan carotids in this case – said yes it is cheap anyway.