The first case was an elderly man with a scar over his right forehead. I was asked to perform the ocular motility examination. He had difficulty in looking up when the eye was adducted. I made a diagnosis of acquired Brown's syndrome possibly caused by the forehead injury. The examiner was pleased with the diagnosis. However, I was told that the Brown's syndrome was caused by drainage of a frontal sinus pyemia and therefore the scar.
This was a slit-lamp examination. The patient was a twelve year old girl. She had bilateral stromal opacities without involvement of the peripheral cornea. I made a diagnosis of macular dystrophy. This was followed by discussion of the genetics of different stromal dystrophies and the histopathological features. The second examiner also asked me the need for corneal graft in different types of corneal dystrophies and the incidence of recurrence
This was slit-lamp examination with a 90D lens. The woman had bilateral myopic discs with peripapillary atrophy. She was also pseudophakic. I did not find any macular changes or Fuch's spots. The discussion centred on the complication of cataract extraction ( risk of perforation during peribulbar anaesthesia, weak zonules and increased retinal detachment) in high myopes and the predictability of biometry in patients with high antero-posterior axial length.
This was again slit-lamp examination with a 90D lens. The patients had bilateral optic disc drusen with unusual branching of the retinal vessels. I also examined carefully for any second pathology but there was no signs of retinitis pigmentosa or angioid streaks. I gave my finding and the examiner asked how I would confirm my diagnosis. I cited autofluorescence in the presence of monochromatic blue light, CT scan and ultrasound. I was asked by the second examiner why optic disc drusen does not autofluoresce with the blue light from the slit-lamp? I suggested that it was because the light was not monochromatic but the examiner did not give me any feedback. I was also asked about the possible complication of optic disc drusen before the bell rang.
The examiner wanted me to perform the ocular motility examination. The patient was a middle-aged male and had bilateral mild ptosis. The examination revealed symmetrical limitation of eye movements. I immediately thought of progressive external ophthalmoplegia with possible systemic association. The examiner was pleased with my clinical findings and asked me what other examination would I perform.
I asked the patient to walk and noted that he had problem performing the heel-to-toe walk. The examiner asked if I would perform any further examination. I mentioned fundal examination and was duly given a direct ophthalmoscope. The patient's eyes were not dilated but with the room dimmed I was able to see some pigmentary changes in the periphery. I made a diagnosis of Kayne-Sayer's syndrome. The examiner seemed satisfied with my diagnosis and asked if I would like to do any further examination. I mentioned cardiovascular examination and also ECG for heart block.
This was a cover/uncover test. The patient was eleven years old. The cover/uncover tests showed orthophoria but on removing the occluder I noted that the patient's eyes moved upward. I made a diagnosis of DVD (dissociated vertical deviation) and suggested that the patient might have previous squint surgery possibly for infantile esotropia.
The examiner then asked me the associated findings of infantile esotropia. I mentioned latent nystagmus, poor binocular vision and asymmetrical opticokinetic nystagmus.
This was an orbital examination. The patient had a unilateral left proptosis which was axial. There was also abnormal vasculature on the conjunctiva. I made a diagnosis of orbital varices.
The second examiner asked me to examine the left optic nerve function. My examination did not reveal any optic nerve abnormalities
I was asked to examine the patient's pupils. Inspection revealed a right partial ptosis and a neck scar. There was anisocoria but no heterochromia. I made a diagnosis of iatrogenic Horner's syndrome.
The questions that followed were the predictable pharmacological diagnosis of anisocoria which I had been asked many times in the mock viva and clinical.
This was an ocular motility examination. The patient had a right sixth nerve palsy and an ipsilateral facial nerve palsy. At first I was thinking of cerebellopontine angle lesion but the patient also had gaze palsy. I made a tentative diagnosis of Foville's syndrome which I had read but could not remember the full syndrome.
The examiner asked about the different types of gaze palsy seen with brain stem lesion including internuclear opthalmoplegia, one and a half syndrome and wall-eyed syndrome.
I was told that this patient had diabetic mellitus and asked to examine his feet. There was ulcer on the pressure point of the right big toe. While I was palpating for the patency of the foot arteries the bell went before I have time to complete performing either vascular or neurological examination on the feet.