|Clinical Problem Solving
A 20-yr old woman has attended the clinic for some time with atopic conjunctivitis.
She has been treated with topical steroid drops but had to discontinue
these because of a steroid induced intraocular pressure rise. On this occassion
she presents with reduced vision of 6/36 right and 6/18 left and seems
to have developed keratoconus. Discuss how you would manage this case and
describe the difficulties and risks involved.
A 75-yr old retired professional man presents to you with sudden loss of
vision in his right eye. On examination acuities are Counting fingers right
and 6/18 left, reading N8. He has a full thickness macular hole in the
right eye with a moderate cataract on the left. Explain how you would manage
this patient and discuss the risks and benefits involved.
The parents of a 6-month old baby girl tell you that there has been a swelling
in her left upper lid since birth which has gradually enlarged. On examination
the left upper lid is swollen and covering the pupillary axis. You also
notice a small capillary hemangioma on the back of her head. Give a differential
diagnosis and describe how you would investigate and manage this patient.
The tricky ones are mostly related to Gen Medicine, Neurology etc….
the ophthal ones are what get you through.
Play safe in this …the rough key here seems to be as follows
If you get 100- 150 right- then u get a 5- which is normal pass
If u get 150-200 u get a 6- definite pass
200-250 u get a 7 which is above average and
250+ u get an 8 which is super brains!!!!
2 examiners- British and Indian
A 10 yr old boy has been referred by a paeditrician who has seen some
abnormal vessels in the peripheral retina…now how do u go about
started with taking a systemic history of diabetes, any abnormal growth
he said ok its an angioma,,, now what will u do.
I described about examination of both eyes then systemic associations
of VHL, isolated also…described about VHL systemic manifestations….and
examination and investigations for it…CT/MRI- Head, USG abdomen etc
He said now how would u treat if the angioma was at the macula
Mentioned about poor prognosis…..and can follow the patient closely….
Showed a Photo of NPDR with CSME
Discussed management and also of PDR and laser settings and complications
Also asked what clinical fundus signs( not on FA) would indicate “macular
I stated that vision would be worse and on FA increased vascular zone
but he said only fundus picture what would make u suspect…
I mentioned irmas and NVE...
65 yr old lady comes with some blurring of vision and red eye ………what
do u do
started with history……since when, pain, trauma, then examine……D/D could
be some keratitis, uveitis,
Asked about management of anterior uveitis, investigations, treatment.
Asked about bacterial and fungal keratitis management and various drugs
for the same
Showed small 35mm projection slide ….( was difficult to see against
the tubelight on the ceiling) .
Myelinated Nerve fibers D/D.
Scar at Macula D/D when I said Choroidal Ruptureas one of the D/D he
asked about mechanism ---coupe contracoupe
General Medicine And Neuro
40 yr old man comes with decrease in vision and some pain also in right
Started with taking detailed history and gave a D/D of ocular conditions
like keratitis, uveitis, optic neuritis…
Then he asked ok now tell me what all things can u do to diagnose optic
Gave him all the list with clinical starting from pupil , fields and
investigations like VEP and role of MRI esp in MS
Then he asked about management…of optic neuritis……..told him about
ONTT and Longitudnal Optic Neuritis Study….
Then he asked about other ophthalmic manifestations of MS
I started with EOM palsies,Horners,
Then he asked me about clinical findings in
Then he asked what is one and half syndrome
I told him and the site of lesion
Then he asked what is webers syndrome
I told him and then he asked about the most commom cause of webers
I told him it can be caused by a SOL, infarction , trauma or demyelinating
disorder but I don’t know the most common cause.
Then he asked what is lat medullary synd…
By this time I had exhausted all my neuroophthal ….and as I was not
very sure about it I told him I don’t know…..and the bell rang.
He asked me all about Diabetes Mellitus – other than ocular stuff
How explain to patient
Basic pathophysiology in Type ! Type 2
Tests to diagnose ….Fasting Blood Sugar, exact values, GTT- how do
u perform and what look for
Prognostic Factors, Risk factors
What tests to diagnose nephropathy?
What he asked was basic but I wish I had been better prepared …..he
had to give hints and elicit answers out of me ….
Then he asked me a clinical situation
75 year old in ward 5 days post VR surgery in GA complains of breathlessness…
what is going in your mind as u r going to the wards
I told him first thing is give a call to chest/ Internal medicine specialist
Then i would be thinking of Pulmonary Embolism
Second would like to know a history of any asthma etc as some drug
given might be precipitating bronchospasm, it could be due to pneumonia,
also other causes
He stopped me and asked what will you do as soon as u reach there
(I followed Mr Samers Advice and) said I will give a repeat call to
chest physician and then check his respiration, BP, look for cyanosis ,
put on pulse-ox, put on Oxygen…….. and auscultate the chest., which would
not reveal much if pulmonary embolism but in bronchospasm- wheezing…………and
then the bell rang….whew……(the longest 20 minutes of my life)
Ophthalmology Surgery and Pathology
First Indian Examiner
He gave me two squint hooks, (one was straight, the normal type and
the other was slightly S shaped – I don’t know what its called )
and asked me what are they and their uses
I told him squint hooks used for engaging the muscle and can also be
used as a lens expressor in extra capsular cataract surgery
He said they are different in shape so tell me what’s the use of the
( S shaped one)
I told him it would be useful to flatten the muscle while suturing
prior to resection as it would cover a broad area…..And he seemed satisfied
Then he asked me tell me the Post op Complications of Cataract Surgery
Started with most devastating is Endophthalmitis and then started giving
a list from Incision Related onwards….
He stopped me and asked how will you manage Post Op Endophthalmitis
I told him its an emergency and based on EVS study would be guided by
the presenting vision of patient….would take a vitreous tap/ biopsy send
for stain+ culture and give intravitreal V+A+D
He asked me how would u take a biopsy and give an intravitreal , whether
in OT or office, what antibiotics, how take tap, with cutter or otherwise
Then he drew a fundus diagram with superior RD extending around 3 clock
hours with an HST,, asked me how will I manage…. And as I was answering
him he asked how would u manage if patient came at 6pm and u don’t
have an anesthetist available for surgery…
It was obvious leading upto Pneumatic Retinopexy, then he asked basic
questions on indications for Pnematic and ideal cases for it…
Then he asked a few basic steps of RD surgery
Next he simply asked to identify a few instruments.. A MAcKintyre’;s
I/A cannula- for which he was very happy when I answered, a lens glide
and then he asked about sutures, nylon, prolene advantages and disadvantages
Second Indian Examiner
Showed a photo of Lower Lid mass ....
Asked to describe and then a D/D,then histopath of BCC and Squamous
Cell CA then how will you manage….and how will you reconstruct…….it was
fairly straightforward…told him it would depend on eventual size of defect
and gave him all the various surgeries in brief.
Asked about sutures u prefer for lid margin……..told him 4-0 silk
Then he asked about DCR anaesthesia….you prefer
And how will u give InfraTrochlear
Then he asked about preferred anaesthesia for Ptosis in adult
I told him a sensory frontal n block and how I would give it…
In this viva table they were not waiting for the whole answer they just
heard the first few things u say and then ask u another question ( they
can assess I guess from the way u speak and what u speak )…so they ask
a lot of questions in those 18 minutes and cover a good breadth…
this was my best viva……among the threee
One Indian and One British Examiner
Had 6 cases
1. Slit Lamp PBK
2. Slit Lamp Bilateral Subluxation with no systemic featuresin
3. Ocular Motility- Pseudo Strabismus- had a large angle kappa
4. 90D – Macular Hole with dense Nuclear Sclerosis
5. Bilateral Ptosis in Adult
6. Fundus I/O- Bilateral healed chorioretinits scars………
The clinicals now I feel was the smoothest….although at that time
it was the most tense time of my life……
Just practice all the steps as given in Chua’s book and website…
Practice desribing your findings as you are examining as it saves time
and you can see more cases in those 40 minutes…
Try and force urself to believe that this patient is in ur clinic and
They asked very basic and direct questions on management in each case
….and were very cordial and helpful, and make u very comfortable…
And you can avail the wonderful material for revision at frcophth@yahoogroups
And u can write to me at firstname.lastname@example.org for any other info…