Candidate 56
Date:  November 2005
Centre: Manchester
Result: Pass
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 Here are the stations I got, as I remember them: 

(1) badly worded question, approximately as follows: "prism effect bifocals. Near segment 8mm inferior, 2 mm medial. What is prismatic effect?" I guessed they were asking the prismatic effect of the distance lens at the near point, and gave the calculation for one eye. 

(2) Humphrey fields, SITA fast. good reliability indices. one was 10-2, with small island of retained central vision, rest of field lost. Other was 24-2, with arcuate scotoma. Definitely looked like glaucoma in BE. Questions: what is the anatomical site of the lesion? What programmes were used and why? 

(3) coronal CT with enlarged rectus muscles bilaterally. IR >> MR > SR > LR. Q: What abnormality is shown? What other clinical features would you expect? [I listed all the features of TED I could think of] 

(4) 2 synoptophore plates. (Bird on one, cage on the other, as I remember it, ie to test simultaneous perception). Q's: what investigation is this. Draw a ray diagram to explain how this investigation works. 

(5) Draw a ray diagram for parallel light rays incident upon a convex mirror. 

(6) Hess chart. Large vertical tropia, but both charts seemed to be the same size, & there was no slanting of either chart, so I'm not sure which was abnormal. I listed some causes of vertical tropias. Asked the principals of hess chart testing. Mentioned dissociation of eyes with mirror (lees screen) or goggles (hess test). 

(7) FFA, rather blurred. Showed smallish patch of leakage at sup-temp macula, near superior arcades. I thought there might be some subtle lacy pattern hyperfluorescence at the same area in the early phases. Asked what was abnormal & principles of FFA. (2cm box to answer this latter question - very cramped!!) 

(8) US B scan, showing retinal detachment. total (cone-shaped) detachment, but retina was quite folded, suggesting it was not under tension, ie rhegmatogeonus, i thought. 

(1) pupil exam. Large right RAPD. Right pupil perhaps marginally larger than left in dark conditions, which didn't make sense in terms of the RAPD. Q's: causes of RAPD? How much retina needs to be detached to cause an RAPD? If the right pupil was larger in dark conditions, which pupil would be abnormal, and what might the causes be? Describe the pathway of the light reflex. 

(2) Ocular movements. Normal VA. No phoria or tropia in primary position. asked to repeat cover test in 8 other positions of gaze. There was some restriction of abduction of the left eye, and severe restriction of left elevation in abduction. No increase to range of movement on covering other eye. I was stopped there. Q's: how you grade over- or underaction? What could the causes of this patient's abnormality be? (mentioned TED, orbital floor +/- medial wall #, ?possibly myaesthenia, was stopped there) 

(3) slit lamp. Right eye ?cornea plana & severe band keratopathy - obscuring view of rest of eye, may also have had cataract? Left eye - less severe band keratopathy, irregular pupil, patient aphakic. Asked what type of surgery they may have had, suggested ECCE (largely becuase aphakia commoner a few years ago when ECCE was standard procedure. Iris sphincter damage also commoner.) Told there was a corneal scar to indicate ECCE, I asked if I could have another look, but still couldn't see it. Asked to demonstrate some other methods of examining anterior segment with slit lamp - demonstrated sclerotic scatter, and was asked how it worked (total internal reflection of light within cornea untill it strikes an opacity). 

(4) Fields. Asked to check field on elderly man. When left eye covered, told me he couldn't see the right half of my face. Left field normal. same findings repeated on finger counting. No hemi-neglect of left eye. Tested fields with white & red hat pins, same findings, but got flustered because I'd found the abnormality so early, used white pin on right eye & then started red pin on right eye before doing white pin on left eye. Asked if I'd always do it that way, apologised & said I'd made a mistake, you should compare white pin field in each eye before starting red. Was asked where lesion was, said as field defect was unilateral, must be anterior to chiasm, i.e., retina or optic nerve. was aksed why i thought it could be optic nerve, said this would usually cause centrocaecal or altitudinal defects, so cause was probably retinal eg RD, sectoral RP, etc. 

(5) Von Helmholtz keratometer on one eye. Wasn't sure how to use it, so examiners showed me a couple of dials. Managed to focus & get some readings. Asked how it worked - regurgitated section form elkington. 

(6) Focimeter. Distance & near on one side of glasses. Distance ok, for some reasonn couldn't get anything resembling a ring of dots (or lines) for the near segment - just a diffusely illuminated blur, not helped by moving th  focussing dial. Guessed near add. Asked how it worked & briefly mentioned light source & collimating lens, plus observation system, change position of illuminating target to recollimate light rays after passing through lens of glasses - ran out of time before I could explain fully. 

(7) Direct. asked to concentrate on discs. looked at right disc first, took a long time because I couldn't see anything wrong with it. Left disc had temporal pallor. Asked what the patient's refractive state was - tried to guess from magnification of image as mentioned in elkington. Asked if i was sure this was the best method, realised i should have looked at the dial on the direct & told them what lens was needed to get disc in focus. Asked what different dials on direct did - mentioned slit to look at elevated lesions, mires to evaluate size, red-free to show microaneurysms & other red lesions. 

(8) indirect. patient kept wanting to chat, but managed to politely shut him up. Asked to use 20D lens - and picked wrong one up. checked it before examining pt & picked up right one. Asked to look at left fundus (with patient sitting up). Disc looked normal, pt had a lot of periperal atrophic patches, some confluent, with pigmented edges. Did not get round to doing macula (I usually do this last). Asked about magnification in myopic & hypermetropic patients, & effects of moving lens away from eye. Also asked what I thought abnormality might be - bell went for end of exam while I was half way through answering. 

Refraction (memories a bit hazy- all rather traumatic)
Examiners very nice & reassuring though. Exam was slow to get started - so had 5 mins of anxious smalltalk with examiners before bell went & i could speak to patient. 

49 year old man, said he was diabetic & had had laser treatment in both eyes (?macular). No surgery. Cover test - tiny phoria ?eso (can't remember). VA approx 6/12 BE. 

Ret: low myope both eyes, approx -1.00D R, -0.50D L, I think. About -0.25 cyl in both eyes, axis at about 90. VA at end of objective 6/9 BE, no improvement with pinhole. Got quite concerned at this stage about the poor VA, although lack of PH improvement slightly reassuring. 

Subjective - slightly reduced the - sphere in both eyes. No significant changes to axis or magnitude of cyl. Duochrome - red in both eyes, changing to green with -0.50 in both eyes. Final distance VA: about 6/9 BE. 

Reading chart was peculiar - ?log scale. had never seen this before, asked examiners if there was an alternative one, told there wasn't. Estimated near add at around +1.50 from age. This seemed fine in right eye, but patient not happy with left eye - wanted more +. Became very worried that I'd over minused in left eye. Ended up prescribing +1.50 in both eyes. 

Maddox rod - patient did not seem able to consistently see dot and line, although I checked I hadn't done anything stupid like occluding one eye or leaving reading add in. After numerous attempts, concluded he was 1PD BO(I think). This was about what I'd expected from cover test. Asked about diplopia, I think he seemed to be getting monocular diplopia left eye. Did not prescribe any prism. 

Finished a couple of minutes early & faffed about trying to recheck subjective refraction in left eye - not able to get any consistent improvement. 

Felt quite sure at the end that I'd failed the refraction, given difficulties with reading add (?overminused L eye?) & maddox rod - but turned out that I'd passed. Presumably he had maculopathy in both eyes. I think I went through routine in quite a slick way considering these problems, had been practising with a local optician until I could (usually) nail the refraction at the ret stage. I certainly recommend anyone thinking of doing part 2 to find an optician to help them ASAP. I also did the nottingham course - perhaps not worth £850, but made me aware that there is more to part 2 than learning elkington, while this needs to be learnt very thoroughly, you also need to get slick at all the exam routines as well, including as much practice refracting as possible. 

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