Candidate 37                                     Centre: Edinburgh
MRCS (Edinburgh)                                               Date: May 2003
Clinical ophthalmology

Case 1
Slit lamp examination. 
LE residual lens matter, no lens. some KP. asked for ddx. I said ant. uveitis, or Fuch's uveitis. Asked about signs of Fuch's heterochromic cyclitis. Asked whether the comment of  no posterior synechiae is valid, I said no, because there was no lens.

Case 2
Fundus with bilateral indirect ophthalmoscopy of an old lady.
I saw a scar at macular. Not allowed to exam further, asked me what will I put
down in my clinical notes. I said disciform scar examiner was happy. 
Then looked at the other fundus, a big big patch of chorioretinal atrophy at inferotemp. region.  asked me to give some ddx. I said toxoplasma,  chorioretinal coloboma.... then told me that this lady got previous radiotherapy to her eye. it was a scar of intraocular tumour after radiotherapy.

Case 3
Pupil exam of an old man. 
Anisocoria,  LE smaller which became exaggerated in darkness. Asked me which side is the pathology, LE. Continue to examine, also got RE RAPD. examiner happy
already. no further question on it. Then was asked what are the ddx of a large abn pupil.Ask me what simple history I would like to take if there is large abn pupil, I said eye drop and trauma. then on the way to the next case,  he asked me
how to dx an adie's pupil. 

Case 4
Asked me to take a history from a man of  50 yr old.
Photophobia since 20 yrs old. bilateral. night vision is completely normal. family hx +++. asked me what is the possible diagnosis. I said cones dystrophy. Then asked me to use 90D to see fundus. I said I can't see a bull's eye maculopathy. Examiner laughed and said 'neither do I' but the patient got a bit of temporal disc pallor. Asked about ERG.

Case 5
A middle age woman with left esotropia. 
Perform extraocular movement, left abduction deficit. Asked me what else I want to do, I did duction. still the same. then I said may be it's a 6th nerve palsy. but examiner not satisfied. Patient has no diplopia. anyway, I was led to the next case. (may be she has chronic eso, with muscle fibrosis, but I wasn't given a chance to say that.

Case 6
Old lady with a left ptosis and frontalis over action. 
Asked what I would like to do. I said check pupil. Asked again what
else. i said EOM and jaw winking. was asked whether jaw winking is likely, i said no. was asked whether jaw winking can occur in patient without marcus jaw winking syn. I didn't know.... then I went back to examine pupil. it was a Horner's. Was asked what is the first thing I ask the patient. I said I like to know if the patient is on pilocarpine causing the small pupil. examiner was happy.

Case 7
Slit lamp examination of an old man. 
He got posterior chamber IOL and trabeculectomy. Asked me to
look at the other eye, same findings. asked me to use 90D look at the disc, it was an increased CDR. He has glaucoma and cataract. that's all the examiner wanted
to know.

Case 8
Slit lamp again of an old lady. 
Easily seen ACIOL. was lightly scolded... 'could u examine in a more
systematic way?' I started from the lid, conj,  cornea and saw a white patch at 9 o'clock. Asked me what was that. I said vogt's limbal girdle, examiner frowned, i
then say it maybe early band keratopathy. he asked what does band k looked like, i said interpalpebral. He was happy. went on to look at the other eye, also
ACIOL. Asked me why she has bilateral. ACIOL, just a postulation. i said she has previous ICCE before the days of ECCE. Examiner nodded. Was asked why should one examine the anterior segment start from temporal side
rather than nasal side... I was blank. then I guess it's for patient's comfort as the light shines on the nasal retina rather than macula first, examiner

Ophthalmology in relation to medicine and neurology

Case 1
90D RE. 
Just some dots blots at macula, no clinically significant macular oedema. Asked
me what is that. I said diabetic retinopathy asked how to classify and what is the patient diabetic retinopathy status. Asked what other illness or condition will cause progression of the retinopathy, I said hypertension, pregnancy. lastly, asked me what is the type of DM. (some candidates got questions like what is the
action of ACE inhibitors and why it is good for DMR....quite difficult questions that would have been for me)

Case 2
Look at the hands of an old lady. 
Rheumatoid arthritic hands, point out the deformities one by one. then look at the elbow got rheumatoid nodules. look at the palm, got palmar erythema. then examiner asked me to look at the face. Other than some telangiectasia, i saw nothing. Was asked about ocular features, regurgitated again. Examiner satisfied. was asked about drug tx of RA. I counted NSAIDs, hydroxychloroquine, azathioprine.....then he asked me what have I left out..... I didn't
know I left out STEROID, he looked annoyed!!!! I saw I got a 5 for this case. looking back, I think I missed a moon face (Note: avoid using Moon face or buffalo hump in the exam use the term Cushingoid features instead to avoid upsetting the patient), as told by other candidates.

Case 3
Look at a woman's facial feature. She had got facial asymmetry.
I volunteered to test for 7th nerve. She also has a tarrsoraphy. was asked why. other than tarsorrhaphy, what else can be done to protect cornea. I answered
lubrication, BCL, botox. examiner was happy. then I said I wanna test other nerves. 5 and 8 are affected too. Was asked where is the pathology. i said cerebello-ponting angle.
Asked what to do, refer to neurosurgeon and CT scan. Examiner nodded.

Case 4
Exam an old man's eyes with a torch. 
I can see  IOL in both eyes and trabeculectomies. Use direct ophthalmoscope to look at disc. BE disc pallor and CDR 0.6-0.8. was asked whether glaucoma alone cause this picture. I said no, the disc won't be that pale. Then asked me what other ddx to consider. then i just regurgitate a whole list of bilateral disc pallor ddx.
examiner looked happy as I went on and on with the possiblities. He told me this man is from a very poor family and has poor diet. What is the cause? I said vitamin deficiency causing optic disc atrophy and the examiner agreed.

Case 5
90D indirect ophthalmoscopy. 
Both discs got some ?new vessels ?collaterals. nothing else in the fundus. asked me the differential diagnosis for new vessels and differential diagnosis for collaterals. asked what to do to differentiate. I said FFA. examiner agreed, and said the
FFA showed no leakage. So it's collaterals. He asked me what are the risks for CRVO, just regurgitated from the books. Before we left, he asked the patient whether he has hypertension, the patient said yes, examiner nodded to me.


More candidates' experience