Scenarios for Practice
Scenario 1: (Appearing in Sept, 2003)

A 60 year-old woman with bilateral myopia of -8.00D and cataract. Explain to her how you will carry out the operation ie. local or general anaesthesia and the choice of implant for the operation. 

Ascertain if the patient wishes to have operation. Explain how the new lens may affect the vision, whether the patient prefer to maintain the same refraction or wishes for emmetropia. Is she happy with local anaesthetic and if not is there any contraindications to general anaesthesia?)

Scenario 2: (Appearing in Sept, 2003)

You are given a referral letter from a GP about a 23 year-old footballer with an unilateral red eye. The patient has been treated with chloramphenicol eyedrop without improvment. You are asked to ask the patients some questions and decide on the appropriate treatment.

(The patient turned out to have Reiter's syndrome. The candidate did not ask about the sexual history and systemic enquiry regarding backache etc as expected by the examiner. In addition, the examiner expected the candidate to inform the patient the effect of mydriatic on his football career.)

Scenario 3:

A 50 year-old man with bilateral advanced glaucoma has just failed his Estermann visual field and you have to tell him that he should not be driving.

Explain the finding to the patient. You may say something like ' We have performed a special test called Estermann test because of your glaucoma. Do you know why we carry out this test?' Find out the patient's need to drive. Is there any support at home?)

Scenario 4:

A 40 year-old woman with a choroidal mass returns for her investigation. The chest X-ray suggests the presence of metastatic carcinoma. 

Verify that the chest X-ray belongs to the patient and let the patient ask the questions for example ' We have been doing some investigations since we discover a lesion within your eye. Do you know why we are doing the investigations?' find out the expectation of the patients then say 'The results of the chest X-ray have come back and there are something showing on the film' or alternatively you can say ' I am afraid we have bad news for you' and the patient will likely to say 'Is it cancer?'. This will be better than come out with sentence like ' You have cancer!')

Scenario 5:

A 50 year-old man with a painful right blind eye. Advise regarding the various options for treating his painful eye including enucleation or evisceration. 

Ascertain the severity of the pain and the patient's desire of keeping an intact globe. If enucleation is contemplated, consider the need for artificial eye service etc.)

Scenario 6: 

A 63 year-old man returns 4 weeks later for a follow up cataract visit. Refraction shows that a wrong lens has been inserted resulting in a hypermetropic shift. The patient is unhappy that he could neither read or see distance without glasses. Explain to him what has happened and the various options open to him including lens exchange and contact lenses. 

Find out how inconvenience it is for the patient. Whether the patient was hypermetropic before the operation and what he had been told about the final refraction prior to the operation? Explain the varioius options open to him.)

Scenario 7:

A 35 year-old has had two failed corneal graft for heretic corneal disease. The cornea is heavily vascularized. He likes to have another corneal graft but you know there is little of a successful outcome. Explain to him why you think a re-graft is not appropriate.

Find out why the patient wants a re-graft and his understanding about the success rate. Is he concerned about the cosmetic effect of a leucoma? In which case cosmetic contact lens may be useful.) 

Scenario 8:

A 69 year-old woman is referred by her GP for possible cataract operation because of very poor vision in both eyes. After examining the patients, you discover that she has minimal cataract and the poor vision is caused by bilateral disciform macular degeneration. Explain to the patient why you think that cataract is inappropriate. 

Explain to the patient what the problem is and why cataract extraction is unhelpful. Use the analogy of a camera to describe the eye for example: ' The lens of a camera is similar to the lens of your eye and the film within the camera is similar to the back of your eye. When the lens is damaged we can replace it with a new one which is similar to a cataract operation. However, if the film is scratchy, changing the lens may not alter the image captured on the camera. The problem you have is similar to a scratchy film so cataract operation will not improve your vision.' If there is a model of the eye present, use it to illustrate her problem. Suggest blind registration or partial sighted registration and low visual aids.)

Scenario 9: 

A woman has a 2 year old child with bilateral retinoblastoma. She is planning a second pregnancy and likes to know the risk of a having another child with retinoblastoma.

Find out how much the patient knows about the conditions and the inherited patterns. Is her partner aware of her desire of having a second child? Is it possible for the partner to be present during the consultation?)

Scenario 10:

You are the only doctor in the minor operating room and the eye unit. A woman is referred directly to you by her GP for a cyst removal from the right upper lid. However, the lesion appears to be a large basal cell carcinoma. You have no experience of excisional biopsy in this area. Explain to the patient why you are not going to carry out the operation on that day.

Find out how much the woman has been told about the lesion. Explain to her your concern and the need for her to be seen by somebody senior. Apologize for the inconvenience cause and arrange an early appointment for consultation.)

Scenario 11:

A 60 year-old man was diagnosed with glaucoma 3 months ago. He was given a beta-blocker to be applied topically twice a day. However, the intraocular pressures remains high and there is deterioration of the visual field. His wife says he is not taking the medication regularly. Find out if he has been taking the medications regularly and explain to him the importance of taking the glaucoma medication.

Drug non-compliance is a common problem. Avoid confronting the patient as the patient may deny it. Instead begin by asking if he has had problems with the eye-drops such as breathlessness and any problems applying them such as rheumatoid hands. Then explain to him the deterioration of the visual field and the risk of blindness and losing his driving license. Mention the alternative such as latanoprost or trabeculectomy.)

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