Observation III

A common mistake in the final MRCOphth/MRCS/FRCS is inadequate examination. This is especially common with slit-lamp examination of the anterior segment. While pathology of the cornea is common in such examination, associated or independent lesion(s) may be present in the fornix or tarsal conjunctiva.

The following cases illustrate the importance of thorough examination; unless the examiner gives you very specific instruction.

This patient has a Lester-Jones' tube in the caruncle. Unless the 
lower lid is everted with the eye abducted, this may be missed. 
A Lester-Jones' tube is shown below

Adrenochrome deposits from chronic use of topical adrenaline for glaucoma is 
another sign which can be easily missed unless the lower lid is everted. The deposits 
most commonly locate in the fornix and the tarsal conjunctiva.

Early signs of ocular cicatricial pemphigoid include obliteration of caruncle, shortening of the fornix and symblepharon. Without lid eversion, these signs may be missed.

Subtarsal fibrosis of the upper lid must be suspected in patients with corneal scarring or neovascularization. As eversion of the upper lid can be uncomfortable for the patient, ask the patient's permission to do so. The examiner may stop you if he thinks this is unnecessary.


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