Candidate 50                                                   Centre: Liverpool
MRCOphth (Passed)                                                          Date: September, 2004

Difficult to prepare for as they are actually very much based on clinical judgement. I spent more time thinking of what I would do if I saw this patient in clinic rather than trying to remember what I’d read in textbooks. A surprising number of surgical questions particularly retinal surgery.


Nothing too unexpected. Subjects covered included: Chlamydia; retinoblastoma and its genetics; preparing patient with MRSA for theatre; actinomycoses; BCC; SCC; OCP (ocular cicatricial pemphigoid) etc.


STATION1: Neuro-ophthalmology and Motility

Case 1: 
Examine EOM. Patient had restriction of abduction of left eye in horizontal plane but apparently good laevodepression and laevoelevation. Reason for narrowing of the interpalpebral fissure on adduction. Commented on this. Asked for diagnosis. I said I thought Duane’s most likely but the normal laevodepression and laevoelevation was atypical. I was told that it was a complex case with no simple answer and could I give any other differentials. Mentioned left 6th and some restrictive causes.

Case 2: 
Inspect this patient. Noted bilateral ptosis. Examine as you think appropriate. Did full ptosis exam without interruption from examiners. Noted lid scars of previous surgery. On testing EOM patient had restriction of almost all movements. Differential? Offered Myasthenia, CPEO, oculopharyngeal dystrophy and Kearnes Sayres

Was told at the end of this station that I should be very pleased and that I had done well

STATION 2: Ophthalmology and Medicine

Case 1: 
Measure this lady’s BP. Hypertensive at 160/90 but said I would like to recheck after 10 minutes. Examine fundi with indirect. Multiple macular and peripapillary chorioretinal scars. Differential? Took a bit of a blank here: POHS, multifocal choroiditis, PIC, MEWDS etc. What treatments would you offer her for choroiditis? Steroids. Any concerns re this treatment? Yes – she’s hypertensive. I would like to consult general physician re control.

Case 2 
Scleral thinning. Differential. Systemic associations of scleritis and of anterior uveitis. Other causes of scleral thinning. Should have been straight forward but somehow wasn’t.

STATION 3: Posterior segment

Case 1: 
Superfield and indirect. Heavy peripheral pigmentation. Differential? Looked like old cryo for RD

Case 2: 
Peripheral lattice and some areas of bone spicule type pigmentaion. Differential.

Case 3: 
Unilateral pale optic disc. Differential. Generally attenuated vessels. Old CRAO.

STATION 4: Glaucoma, cataract and visual fields

Case 1: 
Given history of patient having been referred years ago by optician concerned re something and kept under review but then sudden loss of vision right eye 1 year ago. On examination bilaterally cupped discs. Right macula showed some fibrosis, oedema and haemorrhage. Asked to put it together: said glaucoma complicated by macular BRVO. Examiners happy. Shown Humphrey VF and asked to comment. Did the full description. Arcuate scotoma.

Case 2: 
Visual fields by confrontation. Bilateral constricted fields. Differential: glaucoma; PRP; RP; bilateral occipital infarcts etc. Examine discs. Both cupped.

3rd case which I can’t remember

STATION 5: Communiction Skills

7 minutes taking history from pateint with migraine. 7 minutes counselling regarding diagnosis, management, ocular features, driving and employment.

STATION 6: Anterior segment

Case 1: 
Bilateral penetrating keratoplasty. Peripheral host cornea showed lattice changes. Questions re diagnosis, genetics and presentation.

Case 2: 
Unilateral penetrating keratoplasty. Fellow cornea thinned with stromal scar. Said it was keratoconus. Told to loook again. Said pellucid marginal degeneration. Asked re different types of and indications for grafts. Took ages for examiners to drag the words “tectonic graft” out of me. 

3rd case which I can’t remember. 
By this stage examiners were clearly tired and bored and there was lots of laughing and joking between everyone. Which was unexpected.

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