OSPE (Ophthalmology) for FCPS, FRCOphth, MS & DO Examinee.

Friday, April 7, 2023 [email protected] 1

Objective Structured Practical Question (OSPE)

Subject: Ophthalmology

According to the course curriculum of Bangladesh College of Physician & Surgeon

(BCPS)


AUTHOR:Dr Md Anisur Rahman Anjum.MBBS (Dhaka Medical College). DO (Dhaka University) FCPS (EYE)Associate ProfessorNational Institute of OphthalmologyDhaka, Bangladesh. Chamber: Mojibunnessa Eye HospitalHouse: 18 Road: 6. Dhanmondi, Dhaka, 1205. Bangladesh.Email: [email protected]: 01711-832397

mailto:[email protected]


OSPE:1

Friday, April 7, 2023 4

Question

A 42-year old lady presented with intermittent eye aches. She has shallow anterior chamber in both eyes. Her unaided distant visual acuity 6/6 in OU & her near vision N5 with +1.25 DS in OU. Her anterior segment appeared normal on Slit-Lamp examination. For proper management:

1) Mention 3 relevant clinical tests= 3

2) Mention 1 important investigation for anterior segment = 1

3) Name 3 differential diagnosis.= 3

4) Mention 3 treatment options = 3

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Answer

1) a) Measurement of IOP. b) Gonioscopy. c) Examination of ONH & Peripapillary Nerve Fiber Layer.

2) UBM/ AS-OCT3) i. Primary Angle Closure Suspect (PACS)ii. Primary Angle Closure (PAC)iii. Primary Angle Closure Glaucoma(PACG)4) iv. Anti-glaucoma drugs/ Pilocarpine 2%v. Laser Peripheral Iridotomy (LPI)vi. Trabeculectomy•

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OSPE:2

7

Question

• An 80-year-old man presents with poor vision in his right eye with sudden onset of pain and conjunctival hyperemia. The examination reveals an lOP of 45 mm Hg with a prominent cell and flare reaction without keratic precipitates, a dense cataract, and an open anterior chamber angle.

1) What is the most likely diagnosis?

2) Write 3 D/D.

3) Mention 2 treatment



Answer

1) Phacolytic glaucoma

2) .

i. phacoantigenic glaucoma

ii. ICE syndrome

iii. Fuchs heterochromic iridocyclitis.

3) Medications to control the lOP should be used immediately, definitive therapy requires cataract extraction.

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Explanation

This is the classic presentation of a patient with phacolytic glaucoma. Without keratic precipitates. both phacoantigenic glaucoma and Fuchs heterochrornic iridocyclitis are unlikely. Fuchs heteroch romic iridocyclitis is associated with cataract formation, primarily posterior subcapsular cataracts, but it tends to present in a much younger patient. ICE syndrome occurs in younger patients and causes a secondary angle-closure glaucoma.

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Source:

• Source: American Academy of Ophthalmology Volume: 10. page 108, 109, 110, 111

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OSPE:3


Question

Who is more prone to develop glaucoma & who is the least

Patient a) has IOP >23.75 to ≤ 25.75 mmHg and CCT > 555 to ≤ 588 µm.

patient b) has mean IOP 21.to 23.75 mmHg but CCT ≤ 555 µm

patient c) vertical C/D ratio ≥ 0.50 CCT ≤ 555 µm

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Question

Mention one corneal diseases where IOP is usually below 10 mmHg

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Answer

• Patient C is more prone to develop glaucoma. & patient A is least prone to develop glaucoma.

• Keratoconus

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OSPE:4


Question

An 11-year-old patient presents with red, itchy eyes. On examination, gray, jellylike limbal nodules with vascular cores are seen.

Q:1 This is suggestive of what diagnosis?

Q: 2 Write two D/Ds?

Q: 3 What is the name of limbal nodule?

Q: 4 Over treatment of this patient may cause a vision threatening condition, Mention its name.

Q: 5 Parents of this is patient always very much worried. What advice will you give to them. Mention one advice.

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Check list

1) Vernal keratoconjunctivitis

2) Any two phlyctenular keratoconjunctivitisatopic keratoconjunctivitis superior limbic keratoconjunctivitis

3) Horner-Trantas dots.

4) Glaucoma/POAG.

5) It is a self limiting disease and will cure after teen age.

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Marks Distribution

1) Vernal keratoconjunctivitis --------------------- 2

2) Any two --------------------------------- 2x1.5 = 3phlyctenular keratoconjunctivitisatopic keratoconjunctivitis superior limbic keratoconjunctivitis

3) Horner-Trantas dots.----------------------------- 1

4) Glaucoma/POAG. ------------------------------- 2

5) It is a self limiting disease and will cure after teen age. ----------------------------------- 1 + 1 = 2

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• Vernal keratoconjunctivitis usually presents in older children with symptoms of photophobia and marked itching. A thick, ropy discharge may be present. In limbal vernal keratoconjunctivitis, patients develop gelatinous nodules at the limbus with white centers

(Horner-Trantas dots)

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OSPE:5


Question

This is the Humphrey visual field of a 67 year-old woman.

a. What type of perimetry is a Humphrey field analyser? = 2

b. What does the total deviation measure? = 2 c. What is the pattern deviation? =2 d. What does the visual field show? =1 e. List three conditions which may give this field

defect. =3.

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Answer

a. Humphrey field analyser is a static automated perimetry.

b. The total deviation measures the difference (in db) between the patient's threshold values and that of the age-corrected values.

c. The pattern deviation adjusts the total deviation for any shift in the patient's overall sensitivity. This allows localised area of field loss to be clearly demonstrated.

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Answer

d. Superior arcuate scotoma.e.

i. open angle glaucoma with inferior loss of arcuate nerve fibre layer

ii. optic disc pit

iii. inferior branch retinal vein occlusion

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Explanation

• a. Humphrey field analyser is a static automated perimetry. (In this test, the patient maintains fixation on a central target and the computer randomly presents a brief (about 0.2 seconds) and non-moving ie. static light stimulus at different loci throughout the visual field. The intensity of the light stimulus that the patient can see is then recorded.)

• b. The total deviation measures the difference (in db) between the patient's threshold values and that of the age-corrected values.


Explanation

c. The pattern deviation adjusts the total deviation for any shift in the patient's overall sensitivity. This allows localised area of field loss to be clearly demonstrated.

(Many conditions other than glaucoma can cause poor vision for eg. cataract or corneal oedema. Therefore, to find out how much of a patient’s relative insensitivity to light is due to glaucoma rather than to something else, it is important to "subtract out" these other factors. This can be done because these others conditions tend to produce a similar pattern of diffuse visual field loss, while glaucoma tends to produce localized areas of visual field loss.)


Explanation

d. Superior arcuate scotoma. e.

i. open angle glaucoma with inferior loss of arcuate nerve fibre layer

ii. optic disc pit

iii. inferior branch retinal vein occlusion

(Visual field should not be interpreted without reference to ocular examination. An arcuate scotoma can occur in other conditions other than open angle glaucoma as mentioned above)


OSPE:6


Question

1) What are the advantages of this perimetry over Humphrey perimetry?

2) What are the advantages of Humphry perimetry over Goldman perimetry?

3) What do the numbers 1-4 mean?

4) What do the numbers I-IV mean?

5) What abnormalities can be seen in this visual field?


Answer

1) The main advantages are:

i. The visual field can extend beyond 30 degree.

ii. Stimuli has different size.

2

iii. No examiner bias.

iv. Constant monitoring of fixation.

v. Automated re-testing of abnormal points.

vi. Computer software for analysis.


Answer

3)

They are the intensities of the stimuli.4)

They are the sizes of the stimuli.5)

Nasal steep and baring of the blind spot.

These features are suggestive of glaucoma.


OSPE:7

Give a possible cause for the following field defects.


Answer

A) The visual field shows bilateral altitudinal field defect.

Possible causes include: bilateral ischaemic optic neuropathy (arteritic

or non-arteritic)bilateral superior hemi-retinal artery occlusion bilateral superior hemi-retinal vein occlusion


Answer

B) The visual field shows bilateral constricted visual fields. Possible causes include:

retinitis pigmentosa bilateral dense laser pan-photocoagulation advanced glaucoma C) The visual field shows a left congruous

horizontal wedge-shaped field defect. It is seen in lesion of the right lateral geniculate nucleus such as cerebrovascular accident



OSPE:8


This patient underwent an uncomplicated trabeculectomy. When seen in the clinic three week later, the intraocular pressure measured 27 mm Hg and the slit-lamp appearance is

as shown below.

1) What is the diagnosis?

2) What is responsible for this appearance?


Answer

1) The picture shows a smooth dome shaped elevated cyst. This is typical of a Tenon’s cyst. Encysted bleb,

7/9/20143939Friday, April 7, 2023

2) This is caused by an adhesion between the episclera and Tenon’s capsule so that the aqueous is trapped and not drained.


OSPE:9


17

• This is the slit lamp view of an eye.


QUESTION

1.What is the positive finding in this case? (any 2) 2. What is your diagnosis?

3. Is it an ocular emergency?4. What may be the treatment?

5. Is the fellow eye needs any treatment?6. If yes mention of it.


ANSWER

1) Ciliary congestion Mid dilated pupil, vertically oval. Cornea hazy2) Angle closure glaucoma.3) Yes4) Treatment is surgical, but first reduced IOP with Tab

Acetazolamide and Mannitol inj. And then go for P, I or trabeculectomy according to synechia.

5) Yes6) Pilocarpine 2% eye drop 4 times in a day or prophylactic PI


OSPE:10


Question

1) Name the printout.

2) Describe RNLF Thickness maps?

3) What are the abnormalities in RNFL Deviation maps?

4) Describe TSNIT Graphs.

5) What is NFI & what does it indicate?

6) Mention 2 additional relevant investigations to confirm your diagnosis.


Answer

1) GDx VCC Printout for RNFL Analysis of both eyes = 1

2) Absence of warm colors (Red & Yellow) in both eyes more in left eye indicating thinning/loss of RNFL = 2

3) Appearance of square pixels in superior & inferior quadrants of both eyes. = 2


Answer

4)

I. Double hump patterns of TSNIT Graphs are absent. =1

• II. Graphs are flat.=0.5

• III. inferior humps are more flat. =0.5


Answer

5) Nerve fiver indicator, It’s a Global index ranging from 1- 100.

1-30 indicates normal RNFL Thickness,

31-50 indicates Borderline &

51-100 indicates Thinning of RNFL. = 1

6) • Digital Optic Disc Photography. = 1

• SAP (HVFA/Octopus VFA). =1


OSPE:

11


Question

• Q no 1 What are the disc findings present here?

• Q no 2 Write the provisional diagnosis depend upon findings.

• Q no 3 Write the name of investigations for clinical diagnosis.


Answer

Answer no 1 Increase CDR Narrow Neuro Retinal Rim (NRR) Peri Papillary Atrophy (PPA) Vascular signs


Answer

Answer no 2• Suspicious disc• Physiological cup• Glaucomatous cupping


Answer

Answer no 3• CCT• VF• OCT• HRT


Marks distribution

One for each correct answer

• Q no 1 = 4• Q no 2 = 3• Q no 3 = 3


OSPE:12

1. History taking (Congenital cataract/ Cataract in Children)

Birth History: H/O consanguinity. Maternal infection especially 1 st trimester. Gestational age. Birth weight. Birth trauma, unwanted event during delivery. Supplemental oxygen therapy or being kept in incubator Developmental anomalies. Developmental milestone.




OSPE:13


OSPE=2. History taking of Diplopia

1 Whether double vision is monocular or binocular.

(Causes of monocular diplopia → cataract, astigmatism, corneal scars, keratoconus, tear film irregularity, sublaxated lens, large or sector iridectomy, malingering)

If binocular → ask whether the diplopia is horizontal, vertical or torsional.

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Ask the patient in which direction of gaze is the diplopia worse→ right, left, up, down, right and up, right and down, left and up, left and down, or distance or near.

3) Ask for diurnal variability and fatigability of diplopia suggestive of myasthenia gravis.

4) Detailed history about mode of onset, duration of onset, associated pain, history of strabismus in childhood, history of trauma, neurological symptoms such as dysphagia or weakness,

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Underlying systemic illness such as hypertension, diabetes, cerebrovascular disease, cardiac atherosclerotic disease and multiple sclerosis.

6) History of smoking or alcohol intake should be elicited.


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OSPE:14


Question

Take the relevant history from this SP (Simulated patient) who is suffering from double vision.


Answer

1) Greetings & self introduction--------------------------- 0.25 + 0.25= 0.50

2) Whether double vision is monocular or binocular.------------------- 0.50

3) Direction of double vision: whether the diplopia is horizontal, vertical or torsional.

4) Ask the patient in which direction of gaze the diplopia is worse→ right, left, up, down, right and up, right and down, left and up, left and down, or distance or near.


Answer

5) Ask for diurnal variability and fatigability of diplopia.

6) Detailed history about :

i. mode of onset,

ii. duration of onset,

iii. associated pain,

iv. history of strabismus in childhood,

v. history of trauma,

vi. neurological symptoms such as dysphagia or weakness,


Answer

7) Underlying systemic illness:

i. hypertension,

ii. diabetes,

iii. cerebrovascular disease,

iv. cardiac atherosclerotic disease

v. multiple sclerosis.

8) History of smoking or alcohol intake should be elicited.


OSPE:15

69

History taking of a patient suffering from recurrent uveitis

• Following points to be noted during history taking:

1) PATIENT DETAILS:

Age: Juvenile rheumatoid arthritis (JRA) is common in patients less than 15 years.

Sex: JRA is common in females, HLA – B 27 associated uveitis in males. (but during history taking you should not asked about gender)


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2) OCULAR HISTORY: Is the disease unilateral or bilateral ?When was the first attack?When was the last/current attack?What was the approximate frequency of the

attacks between the first and the last attack?Details of prior ocular treatment.Any previous history of rise IOP or use any

antiglaucoma agents.



3) SYSTEMIC HISTORY: H/O arthritis or low backache (JRA, HLA –B27 related

uveitis). H/O fever or respiratory symptoms, gastro-intestinal,

neurological symptoms, genital lesions. H/O DM, HTN, TB. H/O exposure/ IV drug abuse/ blood transfusions. H/O skin lesions (HZO, Psoriasis) Details of prior systemic treatment.


OSPE:16

History taking R.P

Age of onset of symptoms. Duration of night blindness. Duration of progressive loss of visual field. Duration of dimness of vision . Is it progressive? Family history of R.P. H/O consanguinity. H/O trauma. H/O drug intake. H/O hearing disorder, ataxia, nystagmus.



History taking R.P

• H/O mental retardation.• H/O heart disease.• H/O hypogenitalism, obesity, polydactyly.• H/O diarrhea, skeletal deformity.




OSPE:17


Question

• This 26 year-old woman presented with a two-week history of decreased right vision. The visual acuity was 6/36 in the right eye and 6/6 in the left. Her MRI scan was done. Answer the following question..


Question

1) Is this MRI scan a T1 weighted or a T2 weighted images?

2) What are the advantages of MRI scan over CT scan in brain imaging?

3) What abnormalities are present? 4) What is the likely diagnosis?


Answer

1) T2-weighted MRI. (This is shown by the high signal of the CSF

within the ventricles. In MRI scan of the brain, T1-weighted image is useful for demonstrating anatomical details whereas T2 excellent pathology)


2) The advantages of MRI over CT scan of the brain include:

i. Non-ionising radiationii. Excellent soft tissue contrastiii. Multiplanar images (axial, sagittal and coronal)iv. No artefact from the bone and is especially

useful for posterior fossa imaging.


C) High signal lesions within the periventricular white matter of both cerebral hemispheres

• (These represent multiple plaques of demyelination see figure below, these plaques have high water content and therefore appear white on T2-weighted images.)


D) Multiple sclerosis.

Optic neuritis.


OSPE:18


ANSWER

Coronal planeF.B in the left orbital floor.The following 3 feature may be present restricted upgaze enopthalmos hypoanaesthesia over the left check


T1 weighted & T2 weighted


• Substance T1 weighted T2 weighted• Water/Vitreous/CSF black Light grey or white• Fat White Light grey • Muscle Grey Grey • Air Black Black• Fatty bone marrow White Light Grey• Brain: White matter Light Grey Grey• Brain: Grey matter Grey very light grey


OSPE:19


Question

• Convert the following prescriptions to + or - cylinder notation and state the type of astigmatism which is present in each

1) +4.00 / -1.50 x 70 2) +1.25 / -3.00 x 90 3) PL / +1.50 x 45 4) -2.00 / +2.00 x 50 5) - 1.75 / -2.00 x 135


Answer

a. + 4.00 / - 1.50 x 70 = + 2.50 / + 1.50 x 160 ; compound hypermetropic astigmatism.

b. + 1.25 / - 3.00 x 90 = - 1.75 / + 3.00 x 180 ; mixed astigmatism.

c. PL / + 1.50 x 45 = -1.50 / - 1.50 x 135 ; simple hypermetropia astigmatism.

d. - 2.00 / + 2.00 x 50 = PL / - 2.00 x 140 ; simple myopic astigmatism.

e. - 1.75 / - 2.00 x 135 = - 3.75 / + 2.00 x 45 ; compound myopic astigmatism.


ANSWER

Compound astigmatism occurs when the two principal meridians of an eye are either both hypermetropic ie. compound hypermetropic astigmatism or both myopic ie. compound myopic astigmatism.

Mixed astigmatism occurs when one principal meridian is hypermetropic and the other myopia.

Simple astigmatism occurs when one principal meridian of the eye is emmetropia and the other myopia ie. simple myopic astigmatism or hypermetropic ie. simple hypermetropic astigmatism.


ANSWER


OSPE:

20


Question

• Eight weeks after a left cataract extraction and implant, your patient has the following keratometry:

• 40.00 @90 44.00 @180

1) What is the power and axis of cylinder required to correct the post-operative astigmatism?

2) If a tight radially placed suture is present, in which meridian would you most likely to find it?


Answer

1) There is a 4D difference between the two meridians. So the required cylinder correction is either: - 4.00 X 90 or + 4.00 X180

2) The tight suture is at 1800 and need to be removed.


OSPE:21

Scenario

• A 35 year-old man was assaulted 4 weeks ago with a blunt object over his right temporal region. At the time of the injury, there was no loss of consciousness or ocular injury. However, over the next few weeks, he exprienced progressive swelling and redness of the right eye. There was no medical history of note.

• On examination, the right eye was noted red with moderate non-axial

proptosis.

Scenario

The right conjunctiva showed dilated vessels . The visual acuity VAR= 6/12 & VAL= 6/6. IOP 40 mm of Hg in R/E & 18 mm of Hg in L/E Gonioscopy showed blood in the right trabecular

meshwork Fundoscopy= NAD The proptosis is non-tender to palpation. Bruit can be heard with the bell of a stethoscope

when the eye was closed.

Question

1) What is the most likely diagnosis?

2) What is the gold standard for confirming the diagnosis.

3) What are the mechanisms of raised intraocular pressure in this condition?

4) Is this a life-threatening condition?

5) What are the treatment modalities for this condition?

Answer

1) Direct carotid-cavernous fistula secondary to blunt trauma is the most likely diagnosis.

2) Cerebral angiogram is the gold standard for confirming the diagnosis.(The patient will undergo the investigation under neurosurgical supervision.)

3) Usually it is not a life-threatening condition.

4) The outflow facility is disturbed due to elevation of the episcleral venous pressure.

5) Wait for spontaneous resolution, if not surgery is the treatment of choice.

The current treatment of choice involves endovascular embolization with coils (Fig. 3.23) or balloons which may be transvenous or transarterial.

Friday, April 7, 2023 [email protected] 101THANK YOU

OSPE (Ophthalmology) for FCPS, FRCOphth, MS & DO Examinee.

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Transcript of OSPE (Ophthalmology) for FCPS, FRCOphth, MS & DO Examinee.