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