Clinical case interpretations ( Problem Solving questions )

1. A 32 year old man has a 10 year history of ankylosing spondilitis and associated uncontrolled chronic anterior segment inflammation. He attends your clinic with vision reduced to 6/24 right & 6/36 left and he has developed secondary cataracts with band keratopathy in both eyes. The intra ocular pressure is raised in each eye and he is having difficulty continuing his work as a manager in a warehouse. Discuss the short and long term management of this patient.

2. A 15 year old boy presents with head ache and swelling of his left upper lid. His vision is reduced in the left eye and there is some restriction of eye movement. Discuss how you would  manage him and how you would explain the conditions and risks to the parents. 

3. A 70 year old lady presents with the recent onset of reduced vision in both eyes. On examination visual acuities are counting fingers bilaterally and the right eye has a disciform macular  scar ( less than 2 disc diameter in size ). On the left side there is a large sub macular haemorrhage. The patient has heard that there may be surgery available for macular degeneration. How would you advice and manage the patient ?
 

Viva

Surgery & Pathology

British Examinor
(1)     Slit-lamp photo showing YAG peripheral Iridotomy. Reasons for the treatment and techniques. What are the problems expected during cataract surgery in this patient? Answers: shallow AC and poorly dilating pupil due to long term use of pilocarpine. How would you manage the problems? Increase the bottle height during phaco, use space maintaining visco elastics. Pupil can be dilated with Healon GV / Intracameral adrenaline / Irishooks.What is the likely refractive status in this patient ? Hypermetropic. What formula you will use to do biometry in this patient?

(2) S/L photo showing AC IOL & corneal odema. Possibilities ? endothelial decompensation due to AC IOL. How to manage ? Topical hyperosmotics / stromal puncture / Bandage CL / PKP. How do you do a PKP ? 0.25 mm larger donor corneal button, 4 cardinal sutures, fill in the quadrants with interrupted sutures. What are the advantages & disadvantages of continuous / interrupted sutures ? What are the other forms of keratoplasties ? LK / DLK / DSEK. 

(3) S/L photo. Pseudo exfoliation material at pupillary border. What are the difficulties in cataract surgery ? Poor pupillary dilatation / Zonular dialysis. How to manage ? Endo capsular ring.

(4) S/L photo showing post op endophthalmitis. Treatment? Choice of antibiotics, indications of vitrectomy. Is steroid indicated ? when ?
 

Nigerian Examiner
(1)Lap top photo. Verysise Phakic IOL – Indication ? Refractive surgery. Complications ? very rare – pupillary block, endothelial damage due to poor surgical technique ( complications very rare due to excellent design of the lens) Other forms of refractive phakic IOLs you know ? ICL design

(2)  What are the lasers used in Ophthalmology & its uses 532 Green laser – PRP, grid & focal Red diode laser – TTT YAG – Iridotomy / capsulotomy PDT laser - CNVM
SLT – Glaucoma CO2 laser – Oculoplastics Excimer Laser – LASIK, PRK
Femtosecond laser – Lasik Flap, Kera Ring insertion, Ferara Ring insertion

(3)  Lap Top photo – Color fundus picture – choroidal melanoma. Pathology, cell types, prognosis, treatment modalities. 

( 4) Lap top photo – Large swelling in upper lid – differential diagnosis, surgical options if you suspect malignancy – excision with lid sharing procedures.

(5) BCC involving full length of lower lid – management ? Excision with 3 mm clear margin, frozen section / Mohs micrographic surgery , Lid reconstruction by Mustarde cheek rotation technique.
 

Medical Ophthalmology

Indian examiner
(1)  Lap Top – Color fundus picture – CSR
I asked for FFA, - early venous phase & late phase was shown – the late phase showed  typical leakage. What treatment will you give if he wants immediate recovery ? Laser,  Power & settings ? Mechanism of how the laser works in CSR ?

(2)  Lap top – FFA of LE showing BRVO. Findings on FFA ? Indications of Laser ? BRVO study.

(3) Lap top – Colour fundus photo of CRVO. Findings ? DD ? How to differentiate ischemic & non ischemic CRVO clinically ? RAPD, profound visual loss, extensive cotton wool spots & hemorrhages in ischemic CRVO. FFA picture of CRVO – describe the findings,? What are the indications of laser in CRVO ? CRVO study.

(4) Lap Top – S/L photograph, fluorescein stained with blue filter – few stained spots, possibility ? Dry eye syndrome. How to confirm ? Schirmers test, Tear film break up time, Lissamine Green. Treatment ? Artificial tear drops, punctum plugging, cyclosporine eye drops. Mechanism of action of cyclosporine ? T cell modulation.

British Examiner
(1) A 70 year old man comes to you with  a few days history of shoulder pain, right sided  head ache, decreased vision in the right eye – what you will think of ? GCA How do you confirm the diagnosis ? ESR, CRP & temporal artery biopsy. .How to do temporal artery biopsy ? take 2.5 cm to avoid skip lesions. Why some physicians are reluctant to do temporal artery biopsy ? To preserve temporal artery for any carotid bypass procedure in future. Will you still do a biopsy ? Yes. I will do because giving long term steroid therapy in a 70 year old man is justified only with a biopsy confirmation.

(2) Which is the commonest cranial nerve palsy in the eye ? 6th nerve palsy. What are the common causes in old age ? Diabetes & HT. Commonest cause in young ? MS. How to diagnose MS ? MRI, periventricular plaques. Clinical investigation for MS ? LP

(3) What is immuno compromised status ? examples ? AIDS, Medically induced immuno compromisation after organ transplant. What are AIDS manifestations ? listed. Can chicken pox & HZO occur together ? never occur in individuals with normal immunity. But can occur in severely immuno compromised patients. Prognosis? Very poor

(4)What is primary Sjogrens syndrome ? 

(5) Systemic effects of topical beta blockers.
 

General Medicine & Neurology

( 1) Sudden epistaxis – causes ? Bleeding disorders, anti coagulant therapy – heparin / warfarin, nose picking habit, hypertension. How to investigate ? PT , PTT . What emergency treatment ? pinching the nose, sitting with stooping forward position to avoid aspiration, Inj vitamin K, Platelet transfusion, blood transfusion

(2) Diabetes Mellitus – What is the use of glycoselated Hb ?  to assess long term bood sugar control. Normal range ?    Complications of diabetes mellitus ? Neuropathy, Nephropathy, Retinopathy, Keto acidosis, Non ketotic hyperosmolar coma, Hypoglycemic coma. Classification of anti diabetic drugs.

(3) Old man had unconsciousness and loss of vision but recovered quickly, what could it be ? TIA. Difference between TIA & stroke ?

(4) Old lady in menoposal age group complains of body pain . cause ? Osteo porosis. Treatment ? Calcium & hormones,

(5) Complications of FFA ? Nausea & vomiting, extravasations of dye, Syncope, Anaphylaxis. Management of anaphylaxis ? Airway, O2, Adrenalin 0.5mg IM, IV line, Hydrocortisone 200 mg IV, Chlorpheneramine 10 mg IV, Call physician / Anesthetist, endotracheal intubation if needed.

(6) Patient with bitemporal hemi anopia – cause ? Pitutary tumor, How to investigate ? MRI, CT.

(7) Steroid therapy – Indications, Contra Indications, Complications.

(8) AIDS – Definition, Systemic Manifestations, ocular manifestations, Treatment.

(9) Congenital eye infections- Toxoplasma, CMV, Herpes, Syphilis, HIV.
Manifestations of congenital syphilis – Saddle nose, deafness, underdeveloped teeth, Interstitial Keratitis

(10) Angina – Symptoms, investigations & treatment. Tread mill test, Unstable angina ?
Thrombolytic therapy?

(11) Bacterial endocarditis. Causes, Symptoms, signs, investigations, treatment.
 

Clinical Examination ( Southern General Hospital, Govan Road, Glasgow)

(1) Pigment Dispersion Syndrome (S/L) iris trans illumination defect & endothelial dusting present.

(2) AC IOL. What are the complications ? endothelial decompensation , pupillary block glaucoma.

(3) Thyroid Ophthalmopathy. Patient had exophthalmos, exotropia, diplopia, restricted elevation. What you will look for ? Exposure keratopathy, optic nerve compression ( vision, color vision, field , disc) , thyroid status ( pulse, warmth,  tremor, bruit over thyroid, acropachy, pre tibial myxoedema ) Asked me to demonstrate the ocular motility examination. I did versions, convergence, saccades, cover test for near and 6 meter distance.

(4) RD – Repaired with buckling. I was asked to do indirect with 20 D lens. There was cryo mark and buckle indentation.

(5) Fuchs Heterochromic Uveitis with Pseudophakia. S/L 

(6) Choroidal Nevus. How to differentiate from choroidal melanoma ? elevation, surface, associated RD. What investigation you do ? B Scan, FFA, ICG.

(7) Plexiform Neurofibroma of upper lid (post surgery). Patient had ptosis, scar on lid, Cafe au lait spot on hands, a few fibroma molluscum on neck. Leisch nodules.
 

FRCS Ophthalmology Part B Sample Questions 

MCQ Paper
Please find below some past paper MCQ questions (the answers can be found at the bottom of the page):

1. In a patient who suddenly becomes unconscious:- 

A Examination to determine the cause of the unconsciousness is the first priority
B Securing airway breathing and circulation is the first priority
C In the absence of cardiac arrest the plasma glucose should be checked
D Immediate defibrillation is the first priority
E Placing the coma position will secure the airway without the need for intubation

2. Nerve fibre bundle defect can occur in patients with:- 

A Drusen in the optic nerve head
B Exophthalmos
C Occlusion of the central retinal artery
D Retrobulbar neuritis
E Opticochiasmatic arachnoiditis

3. Dystrophia myotonica:- 

A Is inherited as a recessive trait 
B Is associated with hypogonadism
C Is associated with optic atrophy
D Induces intellectual impairment
E Causes hypoglycaemia

4. The following are typical of Coat's disease:- 

A Areas of capillary non-perfusion on fluoresce in angiography
B Localised retinoschisis
C Progressive leakage of dye from the early frames of the fluorescein angiogram
D Pre-retinal neovascularisation
E Arterio-venous shunts

5. Extracapsular cataract extraction is contraindicated in:- 

A Subluxation of the crystalline lens
B Fuch's heterochromic cyclitis
C Phacolytic glaucoma
D Primary open angle glaucoma
E Proliferative diabetic retinopathy

6. Neurology in relation to ophthalmology:- 

A Bitemporal hemianopic field defects occur in the presence of normal skull x-rays
B 45% of all intracranial tumours arise from the chiasma
C Hypopituitrism with intracranial calcification in a child is suggestive of hypophyseal meningioma
D Occlusion of the middle cerebral artery leads to predominant involvement of the arm and face
E Lesion of the pariental lobe initially cause visual defect in the upper fields while those in the temporal lobe cause a defect in the lower fields
 

Answers
1. F/T/T/F/T 
2. T/T/F/T/T
3. F/T/F/T/F
4. T/F/T/F/T
5. T/F/F/F/F
6. T/F/F/T/F
 

Problem Solving Paper

Please find below some past paper questions including for the final question a specimen answer:

1. A 17-year-old girl is referred to your clinic with a history of increasing prominence of her right eye.  Her general health is good.  Describe how you would investigate and manage this case.

2. An 80-year-old lady attends your clinic with a complaint of gradual vision reduction.  She describes the problem as being greater for close vision rather than distance vision.  She wishes to continue to drive.  Describe how you would deal with this case. 

3. A 42-year-old metal worker attends the clinic with a history of the recent awareness of substandard vision with his left eye.  There is evidence of an afferent pupillary defect.  How would you investigate and manage this case?

4. A 60-year-old lady complains of visual reduction for the last year.  She works as a secretary and now has difficulty seeing her VDU screen.  There is a history of myopia and she previously had successful surgery in both eyes for a retinal detachment 5 years before.  On examination she appears to be developing cataracts in both eyes.  Discuss the risks and benefits of treatment giving your preferred options and the reasons for your choice. 

5. A 21-year-old apprentice decorator is assaulted and has a finger poked into his left eye.  The following day he presents with slight epistaxis and dipopia on down gaze.  Describe your management of this case. 

6. You are asked to see a 35-year-old mother of two children who has a history of ocular toxoplasmosis.  On this occasion she is 20 weeks pregnant and gives a history of distortion and blurring in the left eye.  Discuss the possible causes of her visual symptoms and how you would proceed with the management.
 

Specimen Answer to Question 6

Answer Guide:

A. Differential Diagnosis:  Most likely recurrent Toxoplasmosis
                                             Other causes of uveitis in young person e.g. sarcoid, Ank 
                                             Spond, etc
                                             Related to pregnancy; Hypertension, Toxaemia, Diabetes, 
                                             Osmotic cataract, macular oedema
                                             Other causes of blurred vision per se; Optic neuritis, vein 
                                             occlusion, retinal detachment, Vitreous haemorrhage, CSR, 
                                             ??ION or arterial occlusion (as too young), Tumour/melanoma
                                              Refractive change.

B. Management

History: nature of blurring, duration, onset, severity, intermittent or constant.    Associated symptoms; pain, redness, photophobia, floaters, similar to previous episodes of toxoplasmosis.  Systemic symptoms; general health, pregnancy, fever, weight loss, chest infection, renal problems.

Examination: VA in both eyes, Anterior segments for uveitis, conj injection, IOP, Pupils, lens, vitreous cells and debris, retinal appearance for active toxoplasmosis lesions or old scars, or any of the features mentioned in the D.Diagnosis, involvement of disc or macula and position of focus of inflammation.

Investigations: If toxo, probably need few investigations apart from baseline bloods (FBC, ESR, Glucose, U&E and LFTs). If other causes may need retinal photography and FA but caution as pregnant and some risk to foetus unless FA absolutely essential and diagnosis not possible with slit-lamp fundus exam. Perhaps orbital U/S if poor view of fundus to exclude detachment/solid lesion. Systemic investigations as indicated by history e.g.?CXR if chest infection, other sources of uveitis.

Treatment: decide if treatment is absolutely necessary for toxoplasmosis. Discuss the pros and cons of treatment or not of this condition in pregnant woman: if vision still not too bad and disc and macula not threatened then better not to treat. If vision likely to be permanently affected then need to discuss with obstetrician and pharmacist the best form of treatment.

Treatment: antibiotics; Azithromycin, pyrimethamine + vitamin supplements. Systemic steroids; again risk v benefit in pregnancy, probably safe to give in 2nd trimester if absolutely necessary, but discuss with obstetrician before starting. Topical steroids; safe to give but probably of little help unless anterior Uveitis

Follow-up: monitor closely till condition settles or until side effects with treatment require discontinuation, probably seeing every 1-2 weeks at clinic.

Other Conditions: Almost all of the other D.Diagnosis’s should merely be monitored till baby delivered and then appropriate investigations performed and treatment instituted. Only exception would be retinal detachment, which would require surgery to repair more promptly.