Candidate 51
Date:  November 2005
Centre: Manchester
Result: Pass
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    Direct – dark room. My own direct. Patient with ARMD and sub-hyaloid blood. Had a bit of problem, as I tried to change size of light source whilst looking at macula, and then lost what I was looking at. Asked what I thought diagnosis was (said ARMD with bleed from choroidal neovascularisation). Asked to talk about my direct. Why smaller diameter light for small pupil.

    Indirect – thought I messed this one. Patient sitting up – not laying on bed. Saw what I thought was macula hole (old?). Asked to look at superotemporal region and vasculature. Couldn’t, and said normally for that area would have them lying down. Asked about magnification of 20D and 14D (never heard of 14D). What is the nature of the image with indirect (real and inverted). How do I draw images – said I turned notes round – he said he wanted to know that I have a plan for drawing what I see when using indirect.

    Pupils – had small abnormal pupil. Indirect was nearby. Reacting sluggish to light, ok to accommodation. What do you think? Said Horners. Then asked if that fit with findings on light and accommodation. Said not. “What if pupil was large and those findings?” “Then I’d say Adies”. Couldn’t this be Adies? Ah yes – an OLD Adies can be small.

    Motility. Big proptosed eyes. Eso Hypo tropia of RE. “You should have asked for VA before examining – why do you think that’s important” (if low – patient may not be able to fixate). Diagnosis? TED. What could you do further – examine if restricted eye movements rather than neuro weakness. And check optic nerve function.

    Javal Shciotz keratometer. Patient had irregular astigmatism – so I said by have keratoconus. Asked about use of keratometer – pre op to calculate IOL power and decide incision place. Also mentioned its use in contact lens prescribing. 

    Focimeter – told to do one eye distance and near. Turned spec round for near. Asked about how focimeter works. Told them exactly what Elkington’s book says. Nailed this station. Examiners congratulated me at the end of this station.

    VF – Used my own hatpins. Woman with unilateral supero-nasal VF defect. Obviously obeying midlines. Cause? I said lesion in front of chiasm. Glaucoma, RD, BRVO. Although said I wouldn’t expect any of these to cause field defect that follows midline so well. Anything else? Said I didn’t know. Never found out what was wrong with her.

    Slitlamp – examiner was an arse. Wouldn’t let me speak – “don’t tell me what youre doing – just do it”. So had to “show him” that I was doing sclerotic scatter without talking about it – crazy. Patient had IOLs which were iris supported. Didn’t do or say much to examiner. No idea at the end of it how it went. 

55yr old 6/36 BE uncorrected. She had specs on – so knew she was hypermetropic. Very friendly examiners and patient fortunately. She had NO history. Gave her about +1.75/-0.50 in BE, but axis were 180 RE and 90LE. That concerned me. She was 6/9 after ret. PH made her worse – I don't understand that. Fiddled around subjective on RE to try to improve – axis moved 15 degrees. Examiners said don't bother to try to improve much more on RE - youre not gonna get her better. On LE she preferred 0.25 more on the sphere. No change on the axis - which was a relief. Then I realised Id forgotton duochrome on the other eye. Went back – and she was on green, added +0.25 – she went to the red, and VA unchanged, so incorporated it. Reading add she wanted +2.50. That's massive for 55 yr old, so was concerned. Then had time for motility – she needed less than 1dioptre prism – there was no ½ dioptre prisms in the box. Examiner asked me if I was ready with prescription - I was. They asked if I'd want to add anything else – and they got me to write ADD after the reading add, even though was printed before the box. Bizarre. Walked out unsure – as axis were 90 degrees to each other, and such a massive reading add. With hind sight I should maybe have said I would have liked to look at her macula. 


    CT TED

    Hess – no idea

    Ray diagram of synaptophore

    Working out prismatic effect of specs

    B scan - ?RD/ choroidal detachment

    FFA - ?CSR

Cant remember the other 2. To be honest – OSE was a nightmare. Most people found it hard – especially synaptophore ray diagram. MCQ was also little tricky. Clearly, as they say, you need to nail the OSCE and refraction. Can mess up MCQ and OSE and if nailed the others one can ultimately pass.

My tips– learn to refract early- on a course is what I did. Month before exam – refract COMPLETELY (objective/ subjective/ reading add/ writing it all out) at least once a day – lunchtime is good with patients’ relatives in waiting room. Practice the OSCE stuff weekly, and with any patient in clinic – get your direct/ indirect out and pretend you're in an exam. Sit with orthoptist and learn examining techniques off them couple of months prior to exam. Read Elkington at least twice. Do all the questions on this website. Hope for nice patients and examiners - although that's out of your hand.

Passed exam. First attempt. What a relief…

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