Test 34
(New Matching Paper: Medicine and Neurology in relation to ophthalmology)

In response to considerable discussion the Examinations Committee of the College has decided to update the format of the Part 3 MRCOphth Examination from April, 2003.

An extended matching paper will replace the existing MCQs and they will be no negative marking. The test will probably be easier than the previous format. To familiarize the candidates with the new formats, test 34 and onward will follow the new style as described below by the College.
 

40 questions over a 3-hour period. The questions will be divided as follows. 5 pathology questions 5 microbiology questions 15 general ophthalmology questions 15 Medicine and Neurology in relation to ophthalmology Extended matching questions are multiple choice items organized into sets that use one list of items in the set. The extended matching set includes four components  1.A theme  2.an option list  3.a lead in statement  4.at least four item stems, as illustrated below  This will involve 40 questions (probably 200 stems) over a period of 3 hours.

1. Match the stem questions (a-d) with the options (A-M) listed below:
 

A. III nerve palsy due to aneurysm of       the  posterior communicating artery B. Multiple Sclerosis C. Eyelid oedema  D. Preganglionic Horner’s syndrome  E. Postganglionic Horner’s syndrome  F. Syringomyelia

G. Diabetic III nerve palsy  H. Myasthenia gravis I. Chronic progressive external ophthalmoplegia J. Myotonic Dystrophy K. Kearns Sayre Syndrome  L. Parkinson’s disease  M. Blepharospasm

 

a.	A 35 year old woman has a 10 year history of  progressive bilateral  ptosis. There are bilateral cataract and weakness of lid closure.  The ocular movement is normal.  Answer J. In myotonic dystrophy, there is weakness of orbicularis but the eye movement is normal. In addition, pre-senile cataract is  common.
b.	A 60 year old woman with a 4 week history of headache complains  of horizontal double vision. Examination reveals a right sixth nerve  palsy with mild ptosis and constricted pupil. Answer E. The history suggests a lesion within the cavernous sinus involving the sixth cranial nerve and the sympathetic nervous pathway. One possibility is an internal carotid artery aneurysm. Metastasis is also a possibility.
c.	A 50 year old man who has polydipsia and polyuria develops a  sudden onset vertical diplopia. Examination reveals a right  hypotropia. Pupil examination is normal. Answer G. Polydipsia and polyuria suggests diabetes mellitus.  A hypotropia without pupil involvement suggests a medical partial third nerve palsy.
d.	A 30 year old woman develops a binocular double vision.  Examination reveals limited adduction in both eyes and fine  nystagmus on abduction in either eye. Pupil examination  reveals a right afferent pupillary defect. Answer B. The ocular motility abnormality suggests bilateral internuclear ophthalmoplegia. The pupil abnormality suggests a previous optic neuritis. These signs occurring in a young woman are consistent with multiple sclerosis ie. clinical signs separated in space and time.

2. Match the stem questions (a-d) with the options (A-M) listed below:
 

A. III nerve palsy due to aneurysm of       the  posterior communicating artery B. Lambert-Eaton's syndrome C. Eyelid oedema  D. Neurofibromatosis  E. Postganglionic Horner’s syndrome  F. Syringomyelia

G. Oculopharyngeal dystrophy H. Myasthenia gravis I. Chronic progressive external ophthalmoplegia J. Apraxia of eyelid opening K. Kearns Sayre Syndrome  L. Pancoast's tumour  M. Meig's syndrome

 

a.	A 40 year old woman with a past history of autoimmune hypothyroidism  has asymmetric ptosis and variable diplopia. She has recently developed  dysphagia.  Answer H. Myasthenia gravis is the most likely diagnosis. The sex of the patient,  presence of another autoimmune disorder in this case hypothyroidism  are in favour of the diagnosis.
b.	A 40 year old man has a 5 year history of  progressive bilateral ptosis.  There is restriction of eye movements. He has problem with swallowing.  Muscle biopsy shows abnormal intranuclear inclusion bodies.  Answer G. Tubulofilamentous intranuclear inclusions in the skeletal muscle is  pathognomonic of this condition. The inheritance may be autosomal dominant (seen in French Canadians), autosomal recessive or sporadic.
c.	A 28 year old man has a 1 year history of right ptosis and miosis.  Examination of the upper limbs reveal multiple scars with loss of sensation  to pain but the joint position sense is normal.  Answer F. Syringomyelia is a cause of Horner's syndrome. Sensory abnormality  is typical with loss of sensation to pain and temperature (because the fibres decussate) and preservation of joint and vibratory sense (the fibres travel in the posterior column and do not decussate).
d.	A 25 year old woman has a 10 year history of  progressive bilateral ptosis.  There is restriction of all eye movements but no complaint of diplopia.  There is a pigmentary retinopathy evident.  Answer K. The ptosis and motility problems may be attributed to myasthenia  gravis, chronic progressive external ophthalmoplegia, Kearn-Sayre  syndrome and oculopharyngeal dystrophy. However, pigmentary  retinopathy is seen only in Kearn Sayre syndrome.

 

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