Osce Oftalmología

Objectively Structured
Clinical Examination
(OSCE)
in
Ophthalmology
Objectively Structured
Clinical Examination
(OSCE)
in
Ophthalmology
Amar Agarwal MS FRCS FRCOPHTH

DP Prakash FRCS DNB OPHTHA DO
Sunita Agarwal MS
Athiya Agarwal MD DO
Dr. Agarwal’s Group of Eye Hospitals and
Eye Research Centre
19 Cathedral Road, Chennai-600 086, India
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Objectively Structured Clinical Examination (OSCE) in Ophthalmology

© 2005, Amar Agarwal, DP Prakash, Sunita Agarwal, Athiya Agarwal
All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the authors and the publisher.
This book has been published in good faith that the material provided by authors is
original. Every effort is made to ensure accuracy of material, but the publisher, printer and
authors will not be held responsible for any inadvertent error(s). In case of any dispute, all
legal matters to be settled under Delhi jurisdiction only.
First Edition: 2005

ISBN 81-8061-497-2
Typeset at JPBMP typesetting unit

Printed at Gopsons Papers Ltd, Sector 60, Noida
This book is dedicated to
A great friend and surgeon
Dr Roberto Pinelli,
Italy
Foreword
The evaluation techniques have been put to a critical
scrutiny for a long time. Clinical assessments apart
from being a long and tiring process leave transparency
and bias factor a point of discussion. Short and multiple
choice question formats have reduced the bias and
increased transparency to a great extent in testing the
cognitive skills. Objectively structured clinical
examination (OSCE) has been visualised as clinical
evaluation techniques to eliminate the ambiguity and
bias in the clinical examination.
This book is the first attempt to prepare a sample module to introduce
OSCE to the students of Ophthalmology. The book has good illustrations
along the discrete questions framed to reach with their clear reply. The book
has a good learning material as well as clear and critical analysis of the content
there in.
I am sure that this book will justify its publication and help to promote
OSCE as a friendly induction of a good evaluation technique.
DK Mehta
Director, Guru Nanak Eye Centre
Director, Professor Ophthalmology
Maulana Azad Medical College
New Delhi, India
Preface
Including OSCE (Objectively Structured Clinical Examination) into the DNB
examination is an applaudable decision as it enhances the quality of the
examinations and evaluates the performance of the students in a very practical
and unbiased manner.
On the other hand, students are not trained for this kind of examination
and there is an acute need for more literature on the type of questions asked
and appropriate responses. This book seeks to equip the students with a
suitable knowledge of the system and to enhance their performance in the
examination.
The first of its kind, this book will prove invaluable to all the postgraduate
students whether Primary DNB, DO or MS. It will also make interesting
reading for examiners.
It is a pleasure to present to you this indispensable guide to the OSCE.
Amar Agarwal
DP Prakash
Sunita Agarwal
Athiya Agarwal
Contents
SECTION 1
QUESTIONS 1-25 ...................................................................... 1
SECTION 2
QUESTIONS 26-50 .................................................................. 53
SECTION 3
QUESTIONS 51-75 ................................................................ 105
SECTION 4
QUESTIONS 76-100 .............................................................. 157
SECTION 5
OBSERVATION STATIONS .................................................... 207
Index ................................................................................................... 213

About the OSCE Pattern for DNB Ophthalmology
OSCE
OSCE stands for objectively structured clinical examination. The National
Board of Examinations (NBE) has introduced this new pattern for the DNB
(Diplomate National Board) final clinical examination since 2003. The main
purpose of this new pattern is to examine all the candidates with the same set
of questions even for the clinical exams thereby eliminating any bias that
may occur with different set of questions at different centers. The examination
starts at the same time at all the centers all over India and the students answer
the same set of 25 to 30 questions. Each question is kept in a station or cabin
and the student enters the cabin at the ring of a buzzer. The student gets 5
minutes to read the question and write the answers for the same. At the end
of 5 minutes the buzzer rings and the student is supposed to hand over the
answer for that question to the examiner. Then he moves to the next station
where another set of questions await him which he answers in 5 minutes.
The examination hall is divided into 30 stations and each student occupies 1
station at the start of the examination. At the end of 5 minutes the student
moves on to the next station which was occupied by another student who
also moves on. Thus, all the students get the same set of questions and the
same time of 5 minutes for answering each question. By this process objectivity
is established in the examination. The student has to be alert and stick to the
time limit as he cannot make up for lost time.
The questions for this OSCE pattern are designed in such a way, to examine
the student’s depth and breadth of knowledge in various sub-specialties of
ophthalmology. The questions fall under the following sub-heads, namely:
1. Observation stations.
2. Slit lamp photographs.
3. Fundus photographs and flourescein angiograms.
4. Clinical photographs of squint patients in diagnostic positions of gaze.
5. Clinical investigation reports.
6. Video of surgical procedures.
7. Electro-diagnostic procedure reports.
8. Radiology.
9. Microbiology slides and specimen.
10. Pathology slides and specimen.
11. Refraction techniques.
xiv OSCE in Ophthalmology
12. Recent advances in ophthalmology, and
13. Community ophthalmology.
OBSERVATION STATIONS
In this section the student is asked to perform a clinical examination technique
like slit lamp examination or retinoscopy in front of an observer examiner.
The observer examiner will mark the student in 5 minutes according to the
key given to him. For example: if the question is perform retinoscopy on the
patient dilated with cyclopentolate the marks are distributed in the following
manner:
a. First look for cycloplegia by checking the pupil for light and accommo-
dation—1 mark
b. Wear the trial frame on the patient—½ mark
c. Choose your working distance either ½ meter or 2/3 meter and stick to it
till the end of the examination—½ mark
d. Place the thumb on the slit rotator of the retinoscope and check the
movement in the horizontal and vertical meridians—1 mark
e. Choose lenses systematically and replace the lenses in the trial set—1
mark
f. Write the retinoscopy value as a power cross mentioning the working
distance—1 mark.
From the above it is evident that the student is evaluated on his technique
rather than on the result of the test. Hence, it is important that the student
routinely practice all the observation station questions given in this book
carefully before the examination.
SLIT LAMP PHOTOGRAPHS

Anterior segment photographs may be displayed and questions will be asked.
It is better to first read the question then look at the photograph and then
once again read the question before answering. This is because the questions
may sometimes carry a clue which might be helpful for answering. Try to
keep the answer to the point and be clear. The student has only 5 minutes to
answer and move to the next station.
FUNDUS PHOTGRAPHS
Look at many fundus photographs and fluorescein angiograms of especially
diabetic retinopathy cases. Be sure about classification of retinopathy based
on ETDRS and similarly for ROP.
About the OSCE xv
SQUINT
The student will most likely be shown photographs of squint patients in all 9
diagnostic positions. Read the photograph carefully and systematically from
the primary position then proceeding to the versions and finally the elevation
and depression. Formulate the diagnosis based on the photograph and any
clue that may have been given in the question in the form of history.
VIDEO OF SURGICAL PROCEDURES

The student may be shown a video of surgical procedures like phaconit,
phacotrab, penetrating keratoplasty with IOL, viscocanalostomy or lasik laser.
It is advisable to first read the questions and then see the video to look for
answers. This section will have the latest surgical procedures and the student
is advised to be abreast with recent trends.
INVESTIGATIONS
Electroretinogram, VEP, EOG, orbscan, aberrometry, field test reports, Amsler
charts and any other diagnostic report may be shown and questions asked
on it. The student has to familiarize himself with the results, their limitations,
etc.
RADIOLOGY
CT scans, MRI scans, ultrasonography pictures, X-rays or any other procedure
like dacryocystography may be shown and questions based on that. The
student should be familiar with the method employed to take the scan for
example: whether it’s a T1 or T2 weighted image in MRI scanning.
MICROBIOLOGY AND PATHOLOGY SLIDES AND SPECIMEN

Procedure of Gram’s staining and KOH mount are important. Look at the
question first before looking at the slide as the question might carry a clue as
to which structure is mounted.
COMMUNITY OPHTHALMOLOGY
The student may be asked about the National Blindness Control Programme
or about any nationwide programme like, vit-A supplementation or eye
banking.
SUMMARY
In the OSCE pattern the student will be tested in all branches of ophthalmology
without bias and objectively. The student should prepare for the OSCE exams
xvi OOSCE in Ophthalmology
in a systematic manner to come out successful. The total marks allotted for
the OSCE exams is 150 and it is theoretically-possible to score full marks. As
of now there is no negative marking in the OSCE examinations and hence
the student is advised to attempt all questions. A student by and large will
have to pass the OSCE test to pass the total clinical examination.
Section 1
Questions 1-25
QUESTION 1
A 29-year-old married 5 feet 5 inches lady weighing 89 kg has sought
consultation for blurring of vision in both eyes lasting for few seconds for the
past three months. Her visual acuity in 6/6. Her fundus photograph is given
below.
1. What is the condition of the optic disc based on the fundus photograph?
2. Write three D/D of this condition.
3. Write the visual field defect of this condition.
4. What ophthalmic examinations will you perform to arrive at a diagnosis
for this patient?
4 OSCE in Ophthalmology
ANSWER
1. Bilateral disc swelling.
2. Malignant hypertension, benign intracranial, hypertension, bilateral optic
neuritis, space occupying lesion in brain.
3. Enlarged blind spot.
4. Color vision, visual acuity and pupils for RAPO and ocular motility.
Section 1 5
QUESTION 2 (CONTD... Q. 1)
5. At what intracranial pressure does spontaneous venous pulsation
disappear.
6. History of which drug intake is relavent in this patient.
7. What treatment will you start first in this patient, if CT scan blood pressure
and color vision are normal?
8. Which type of optic atrophy will result from this condition?
ANSWER (CONTINUATION OF Q. 1)
5. 175 mmHg.
6. Oral contraceptive pills, fast tapering of steroids, tetracycline, quinolones,
vitamin A high dose, phenytoin sodium and phenathiazines
7. Weight reduction, oral acetazolamide.
8. Secondary optic atrophy.
Section 1 7
QUESTION 3
A 75-year-old male came for change of glasses. His fundus photograph is
given below.
1. Identify this condition.

2. Do you expect the vision of this patient to be affected by the finding seen
in this fundus photograph.
3. What are the white lesions in fundus photograph made of?
4. At what level are they located anatomically.
5. What test can this patient perform at home everyday to monitor the
progress of this condition?
ANSWER
1. Dry age-related macular degeneration.
2. No.
3. Basal laminar deposits and basal linear deposits.
4. Between basal lamina of retinal pigment epithelium and inner collagenous
layer of Bruch’s membrane.
5. Amsler’s grid test.
Section 1 9
QUESTION 4
A 45-year-old lady has sought consultation for sudden onset defective vision
in her right eye. Her vision was perception of light. This fundus photograph
and angiogram were taken one day later.

2. What is cause of the hypofluorescent area surrounding the disc seen in
angiogram?
3. Name one clinical general examination and one ocular clinical examination
that will you like to perform in this patient which will help you to identify
the cause of this condition.
4. What complication in anterior segment can result as a consequence of
this condition and what is the incidence?
ANSWER
1. Ischemic central retinal vein occlusion.
2. Blocked fluorescence due to retinal hemorrhages.
3. Blood pressure and applanation tonometry.
4. Neovascular glaucoma 60%.
Section 1 11
QUESTION 5
A 29-year-old male patient complaints of defective vision in his left eye.
Best-corrected visual acuity is 6/24.

2. What could be the cause of reduced visual acuity in this patient?
3. What can be done to improve the visual acuity of this patient?
4. Write four findings from this FFA.
5. What is the finding seen in the angiogram just above the disc and what is
its significance relating to etiology of this condition?
ANSWER
1. Inferotemporal branch vein occlusion.
2. Macular edema.
3. Retinal grid laser photocoagulation after resolution of retinal hemorrhages.
4. Blocked fluorescence corresponding to retinal hemorrhage, hyper-
fluorescence corresponding to leakage of dye, macular edema and
narrowing of vein distal to branch retinal vein occlusion.
5. Blocked fluorescence corresponding to flame shaped hemorrhage
probably hypertension.
Section 1 13
QUESTION 6
Look at the fundus photograph and answer the question below.
1. What is the diagnosis?

2. What is the classical description of the FFA in this patient?
3. What is the size of the lesion?
4. What are the visual complaints the patient likely to have?
5. How will you treat this patient?
ANSWER
1. Central serous retinopathy.
2. Smoke stack pattern in macula.
3. 4 to 5 disc diameters
4. Micropsia, metamorphopsia, positive scotoma and dimness of vision in
reading.
5. Rule out the cause and conservative management up to six months since
leak is close to center of fovea.
Section 1 15
QUESTION 7
1. What is anterior segment complication of this condition?

2. What is commonest cause of this problem?
3. What is pathogenesis of this problem?
4. How you treat this problem?
5. Will cataract surgery precipitate this problem.
ANSWER
1. Rubeosis iridis.
2. Diabetes mellitus.
3. Retinal hypoxia causing elaboration of angiogenic factors causing
neovascularization.
4. Laser photocoagulation of retina or vitrectomy with endolaser if media is
too hazy.
5. Yes.
Section 1 17
QUESTION 8
1. Describe the findings in these photographs?

2. Why is healing delayed in such kind of patients?
3. How can you promote healing in this patient?
4. What are the causes of this bilateral problem?
ANSWER
1. Atheromatous ulcer showing epithelial defect, corneal opacity, hypopyon
and vascularization.
2. Cornea is insensitive and denervation of cornea causes delayed healing.
3. Lubricants, Bandage contact lens, Amniotic membrane transplant,
Collagen membrane and Penetrating keratoplasty.
4. Exposure keratitis in comatose patients, Bilateral facial nerve palsy due to
Moebius syndrome, Guillain Barré syndrome, Sarcoidosis, Leprosy,
Mumps, Lyme disease and HIV.
Section 1 19
QUESTION 9
Top pictures are preoperative photograph and bottom pictures are
postoperative.
1. What surgical procedure has been done?

2. What is the visual prognosis?
3. What is the other alternative procedure for this patient?
4. What is the main symptom for which patient will seek consultation for?
ANSWER
1. Gunderson’s procedure. Conjunctival hooding of the cornea for bullous
keratopathy.
2. Poor.
3. Penetrating keratoplasty.
4. Pain and watering.
Section 1 21
QUESTION 10
1. Evaluate the fit in top photograph.

2. Evaluate the fit in bottom photograph.
3. Can you alter the diameter of lens to achieve perfect fit? How?
4. Can you alter the base curve in bottom fit? How?
5. What is the complication of bottom fit?
ANSWER
1. Flat fit.
2. Steep fit.
3. Yes by reducing the diameter of a steep lens or by increasing diameter of
flatter.
4. Yes increase the base curve to make base flatter.
5. Pain and edema (tight lens syndrome).
Section 1 23
QUESTION 11
1. Of the four photographs, which is the best fit?

2. What is ideal fit?
3. What is RGPL lens made up of?
4. Of what material hard contact lens made up of
5. Can a semisoft lens be folded?
ANSWER
1. Bottom right photo.
2. Minimal central fluorescence, midperipheral touch and peripheral edge
lift.
3. Polysiloxane and CAB cellulose acetate butyrate.
4. PMMA.
5. No.
Section 1 25
QUESTION 12 (CONTD... Q. 11)

6. What is symbol of oxygen transmissibility of CL?
7. What is the unit of oxygen transmissibility?
8. Is oxygen transmissibility temp dependent?
9. What is minimum oxygen transmissibility for extended wear CL?
10. What is the diameter range of soft CL?
ANSWER
6. DK/L.
7. Fatt units.
8. Yes.
9. More than 36.
10. 13.0-14.5 mm.
Section 1 27
QUESTION 13
1. Give three differential diagnosis for this picture?

2. What is the most dreaded complication of this problem in a 5 years old
child?
3. When this problem clears in which direction its clears?
4. How will you treat this child?
5. What is the cause of this problem?
ANSWER
1. Anterior subluxation of lens, corneal blood staining, corneal opacity.
2. Glaucoma and amblyopia.
3. Clears from periphery.
4. Penetrating keratoplasty.
5. Long standing total hyphema.
Section 1 29
QUESTION 14

2. What is the haptic made up of?
3. What is the visual problem?
4. What are the complications of this problem?
5. What is the management of this case?
ANSWER
1. Dislocated IOL with erosion of haptic in sub-conjunctival space.
2. Polypropylene.
3. Diplopia and astigmatism.
4. UGH syndrome, endophthalmitis, conjunctivalization of cornea.
5. Explantation of IOL with reimplantation of IOL in anterior chamber/sulcus/
posterior chamber depending on integrity of posterior capsule.
Section 1 31
QUESTION 15

2. What is the whitish material made up of?
3. What is the complication?
4. What problems do you anticipate during cataract surgery of this patient?
5. Draw the findings on ant lens capsule in a typical case.
ANSWER
1. Pseudoexfoliation.
2. Fibrogranular similar to amyloid and hyaline.
3. Secondary open angle glaucoma.
4. Non-dilating pupil, CCC difficult, zonules weak with subluxation of lens.
5. The findings on ant lens capsule.
Central zone
with ragged borders
Middle clear zone
Peripheral zone
with ragged margins
Section 1 33
QUESTION 16

2. Name two ocular causes for this condition
3. Why is this problem in this part of the cornea?
4. What is the nature of the abnormal material in the cornea?
5. How can we treat this condition?
ANSWER 16
1. Calcific band keratopathy.
2. Uveitis due to Juvenile chronic arthritis, chronic glaucoma, systemic
hypercalcemia. And hypocalcemia following renal failure.
3. Due to continuous evaporation of tears there is precipation of calcium
salts in the interpalpebral cornea exposed to evaporation.
4. Calcium deposits.
5. Chelating agents like topical EDTA and lamellar keratoplasty.
Section 1 35
QUESTION 17
RE
LE
1. What are the causes of such conditions in a 40 years old man?

2. What precautions would you take while operating the right eye?
3. Which IOL power calculation formula is advisable to use if this patients
axial length were to be less than 21 mm.
4. What is the embryological origin of the human lens?
ANSWER
1. Diabetes mellitus, steroid intake, myotonic dystrophy, atopy and uveitis.
2. Use trypan blue dye to stain the anterior capsule and a B scan examination
to rule out posterior segment problem.
3. HOFFER Q
4. Surface ectoderm.
Section 1 37
QUESTION 18
1. What refractive error is likely to be caused by this lesion?

2. What is name given to iron deposition in cornea ahead of the advancing
edge of the pterygium?
3. What is the histology of this condition?
4. What treatment would you suggest for this patient?
5. What are the complications of the treatment?
6. What are the treatment options available for recurrent lesions?
ANSWER 18
1. With the rule astigmatism.
2. Stoker’s line on slit lamp examination.
3. Elastoid degeneration of collagen with appearance of subepithelial
fibrovascular tissue.
4. Excision of the pterygium with conjunctival autograft.
5. Corneal and scleral thinning and perforation, Injury to medial rectus
muscle, corneal opacification and recurrence.
6. Conjunctival autograft, intraoperative or postoperative of mitomycin-C.
Section 1 39
QUESTION 19
1. What is the condition seen in the nasal corneal limbus of this patient?
2. What is the pathology behind this condition?
3. Name three causes of this condition?
4. How will you treat this condition?
ANSWER
1. Dellen.
2. Localized thining of cornea due to drying up, desiccation and compaction
of the corneal collagen fibers.
3. Pinguecula, pterygium, limbal dermoid, and other limbal nodules.
4. Lubricants and patching.
Section 1 41
QUESTION 20
1. What is the vertical line seen in the cornea called?

2. What is the pathogenesis of this vertical line of which in layer of the cornea
this seen?
3. What do you expect will the pachymetry this cornea to be?
4. What are the causes of such a pathology—Name four?
5. What is the definitive treatment for this condition?
ANSWER
1. Striate keratopathy.
2. Folds in the descement membrane.
3. Thick cornea.
4. Fuch’s endothelial dystrophy, congenital hereditary endothelial dystrophy,
pseudophakic and aphakic bullous keratopathy and herpes zoster keratitis.
5. Penetrating keratoplasty with explained prognosis.
Section 1 43
QUESTION 21
1. What is the abnormality seen in the lower part of the first photograph?
2. What is it composed of?
3. What are the causes of such an abnormality in a red eye (3 causes)?
4. What are the causes of such an abnormality in a white eye (3 causes)?
ANSWER
1. Hypopyon.
2. Polymorphonuclear leukocytes and inflammatory exudates.
3. Behçet’s disease, Ankylosing spondylitis, Sarcoidosis, Endophthalmitis.
4. Retinoblastoma, Juvenile chronic arthritis, Toxoplasmosis.
Section 1 45
QUESTION 22

2. What are the indications for steroid therapy?
3. How long this problem take to resolve?
4. What is the differential diagnosis for this condition?
ANSWER 22
1. Superficial punctate keratitis.
2. Corneal infiltration in pupillary region which hampers the vision.
3. One week to one year.
4. Adenoviral keratitis, Keratitis medicamentosa, Herpes zoster.
Section 1 47
QUESTION 23
1. What is the anterior chamber depth?

2. Is the cornea edematous?
3. What is the differential diagnosis considering that the eye is white and
pain free?
4. What do you expect IOP to be?
ANSWER
1. Shallow anterior chamber.
2. No.
3. Old retinal detachment, old choroidal detachment.
4. Low.
Section 1 49
QUESTION 24
1. What is the principle behind this investigation?

2. Give three uses of this investigation.
3. What is the minimum corneal thickness in this patient?
4. What is the elevation of the anterior best fit sphere?
5. What is the astigmatism of this patient?
ANSWER
1. Three dimensional slit scan technology.
2. Screening of patients for LASIK, contact lens fitting and evaluation of
astigmatism change.
3. 573 m.
4. 0.017mm.
5. + 1.8D @86 deg.
Section 1 51
QUESTION 25
1. What does red color in the upper left map indicate?

2. Which map is best representative of corneal astigmatism?
3. Is this patient ideal for keratorefractive surgery? Why?
4. Comment on the posterior corneal elevation.
5. What do the numbers inside white circles in the lower right map mean?
ANSWER
1. Red color indicated steep cornea corresponding to 0.060 mm elevation
from anterior best fit sphere.
2. The lower left map is best representative of the corneal astigmatism.
3. No this patient is not suitable for keratorefractive procedures like LASIK
because of the ectasia of the anterior and posterior cornea with thinning
suggestive of keratoconus.
4. The avg posterior corneal elevation in this patient is 0.071 mm from the
posterior best fit sphere. This is highly suggestive of posterior corneal
elevation.
5. The numbers inside white circles in the lower left map indicate local corneal
pachymetry readings in those areas of the cornea.
Section 2
Questions 26-50
QUESTION 26
1. What is this investigation?

2. What is the principle behind this investigation?
3. What do the red colors in the picture represent?
5. What is the treatment for this condition?
ANSWER 26 (OCT MAC HOLE)

1. Ocular coherence tomography.
2. Low coherence continuous waves are used to tomographicaly analyze
the retina. The principle of temporal interference is used. The time delay
of the waves reflected from various layers of the retina is calculated and
analyzed.
3. The red colors represent the nerve fiber layer cortical vitreous interface in
the top and the RPE choriocapillary layer in the bottom.
4. Full thickness macular hole without operculum.
5. Vitrectomy is useful for stage 2 and above holeswith vitreomacular traction.
It may not be beneficial for stage 4 holes where PVD has occurred.
Section 2 57
QUESTION 27
1. What is the abnormality seen in the picture?

2. What is the resolving capacity of this investigation?
3. Which other investigation will help us in deciding about the management
of this patient?
4. Name three causes of this abnormality.
5. Name two non-surgical treatments that we can offer such type of patients.
ANSWER 27 (OCT SRNVM)

1. A bright red reflex in the space between the RPE and the neurosensory
retina most probably due to a SRNVM.
2. 10 to 15 microns.
3. Fluorescein angiography and indocyanine green angiography.
4. ARMD, myopia, choroidal rupture, trauma, angiod streaks, presumed
ocular histoplasmosis syndrome.
5. Argon laser photocoagulation of the SRNVM and photodynamic therapy
with vitreoporphyrin(visudyne) dye.
Section 2 59
QUESTION 28
1. What is the black dome shaped area due to?

2. What are the usual fluorescein angiographic findings characteristic of this
condition?
3. What is the condition of the retinal pigment epithelium in this photograph?
4. What is the natural course of this condition?
5. What refractive error can be caused by this condition?
ANSWER (OCT CSR)

1. The black dome shaped area is due to accumulation of fluid between the
RPE and the neurosensory retina.
2. Smoke stack and ink blot patterns.
3. The RPE looks normal.
4. Spontaneous resolution within 6 months with occasional recurrences.
5. Hypermetropia.
Section 2 61
QUESTION 29
1. What is this condition?

2. What is the black area inside the green area due to?
3. Name 4 causes of this condition.
4. Is there vitreomacular traction seen in this photograph?
5. Name two drugs that can be used to treat this condition.
ANSWER
1. Cystoid macular edema
2. Cystic spaces in the neurosensory retina.
3. Any intraocular surgery, idiopathic, RP, CRVO, BRVO, diabetes, and
trauma.
4. No. There is no vitreoretinal traction.
5. Oral indomethacin and topical steroids, and NSAIDs like ketorolac
tromethamine.
Section 2 63
QUESTION 30
COVER TEST
• First ascertain whether patient can fixate on the torch light and maintain
fixation with each eye.
• Assess the deviation in primary position with Heshberg test. Note primary
deviation with apparently normal eye fixing and secondary deviation with
apparently deviating eye fixing.
• Cover the fixing eye and note the movement of the deviated eye to take
up fixation.
• Remove cover from the covered eye and note the movement of that eye
and the movement of the fixating eye.
• Look for any nystagmus that has occurred only during the cover test-
latent nystagmus.
• Repeat the same procedure with the deviated eye.
• To detect the presence of a phoria do the alternate cover test.
ANSWER
Cover test
Cover RE; observe LE
LE moves LE does not move
Tropia Cover LE; observe RE
Uncover RE; observe LE RE moves RE does not move
Be move No movement Tropia No tropia
Alternately
LE monocular Alternating Uncover LE; cover RE then LE,
tropia tropia observe RE observe the
uncovered eye
Be move No movement Movement No movement
RE monocular Alternating
Phoria Orthophoria
tropia tropia
Section 2 65
QUESTION 31
Left eye Right eye
Ob lat. p
Rec. sy
p Ob lat. Rec. sy
Rec Sup Ob in. Rec Sup Ob in.
Rect ext Rect ext Rect int Rect int Rect int Rect int Rect ext Rect ext
Nasal
Rect int Ob. sup. Ob. sup. Rect int
Ob. sup. Ob. sup.

Rect int Rect int
Green before left eye Green before right eye
1. What is the color of glasses worn before the test eye?

2. What is the color of the pointer the patient has?
3. What is the color of the led in the screen?
4. What is the principle of this test?
5. Which is the fixing eye if red glass is in front of the right eye?
ANSWER
1. Green color.
2. Green pointer.
3. Red color.
4. Foveal projection and haploscopic principle.
5. Left eye.
Section 2 67
QUESTION 32
Left eye Right eye
Ob lat. p
Rec. sy
p Ob lat. Rec. sy
Nasal Temp
Ob. sup. Ob. sup.

Rect int Rect int
Luthra surgical works

1. What is the position of the right eye in primary gaze?

2. Which is the pathological eye and why?
3. What is diagnosis?
4. What muscle sequelae are seen in this charting?
5. At what distance is this test performed?
ANSWER
1. RE 5 degree esotropia.
2. RE is pathological eye because field is small in right eye.
3. RE lateral rectus palsy.
4. Overaction of RE and LE medial rectus.
5. 50 cm.
Section 2 69
QUESTION 33
Left eye Right eye
Ob lat. p
Rec. sy
p Ob lat. Rec. sy
Nasal Temp
Ob. sup. Ob. sup.

Rect int Rect int


2. What is the position of the eye in primary gaze?
3. Is it a long standing or an acute problem and why?
4. Can you comment about torsional deviation from this Hess chart and
how?
ANSWER
1. RE superior oblique palsy.
2. RE hypertropia 7 degrees.
3. Longstanding palsy due to fact that inhibitional palsy of the antagonist of
the yoke muscle.
4. We cannot comment on torsional deviation on Hess chart because we
are using spot targets. If we use linear targets than torsional deviations
can be made out.
Section 2 71
QUESTION 34
Left eye Right eye
Ob lat. p
Rec. sy
p Ob lat. Rec. sy
Nasal Temp
Ob. sup. Ob. sup.

Rect int Rect int


2. What is the position of left eye in primary gaze?
3. Is the plotting reliable?
4. What are the limitations of Hess charting?
ANSWER
1. Left inferior rectus entrapment following blow out fracture.
2. LE is hypotropic in primary gaze.
3. Yes the plotting is reliable as inner and outer fields are plotted.
4. We can do Hess charting when vision is good, retinal correspondence
should be normal and normal color vision.
Section 2 73
QUESTION 35
1. What is the chemical name of this gas?

2. Inside the eye how many times its original volume does it expand?
3. How long does it stay inside the eye?
4. What are the two physical properties of an intravitreal gas that assist in
closure of a retinal break?
ANSWER
1. Sulphur hexa fluoride.
2. Twice its volume.
3. 12 to 14 days.
4. Surface tension and buoyancy.
Section 2 75
QUESTION 36
1. Which location of a retinal break is most unsuitable for pneumatic
retinopexy?
2. The gas bubble attains its largest size after how many hours?
3. What is the main disadvantage of pneumatic retinopexy?
4. Name 3 retinal conditions in which pneumatic retinopexy is idealy
preferred?
ANSWER
1. Breaks located in the inferior 4 clock hours of the retina are most unsuitable
for pneumatic retinopexy.
2. A c3f8 gas bubble attains largest size after 72 hours where as the sf6
bubble attains its largest size after 36 hours of injecting into the eye.
3. Postoperative positioning of the patient so that the break is at the highest
point of the retina and the fact that postoperatively its very difficult to
examine the patient are the most significant disadvantages of pneumatic
retinopexy.
4. Pneumatic retinopexy is ideally suited for macular holes with detachment,
isolated breaks under the superior rectus muscle, presence of a functioning
filtering bleb, extensively scarred conjunctiva and optic disc pit with
macular detachment. Apart from this patient factors like unfit for GA and
cost of Rd surgery are also relative advantages of pneumatic retinopexy
over conventional Rd surgery.
Section 2 77
QUESTION 37
1. Identify this instrument. Who invented it?

2. What is the function of the sleeve that covers the tip of this instrument?
3. What is surge?
4. Name the 3 important parameters that have to be preset before start of
surgery.
5. What is the size of the incision that has to be made in the eye to introduce
it into the eye?
ANSWER
1. Phaco hand piece. Charles kelman.
2. The silicon sleeve that covers the tip helps to insulate the corneal wound
of entry and serves to direct the infusion fluid into the anterior chamber.
3. Sudden shallowing of the anterior chamber when occlusion of the phaco
tip breaks is called surge. It occurs because the outflow of fluid from the
anterior chamber exceeds the inflow in to it momentarily.
4. Power, vacuum and aspiration flow rate have to be preset before start of
surgery in a peristaltic machine. In a venturi machine the aspiration flow
rate is automatically set to 1/3 of the preset vacuum.
5. An icision of 2.4 min to 3.2 mm has to be made to introduce the phaco-
tip in to the eye.
Section 2 79
QUESTION 38
1. Is the field reliable? Why?

2. What does 30-2 signify?
3. Comment on the difference between the total deviation and pattern
deviation.
4. What does asb stand for?
5. What is the pattern standard deviation of this test and is it significant?
ANSWER
1. The field is not reliable because the fixation loss exceeds 30%. In this field
it is 70%.
2. Thirty signifies central 30 degees and 2 indicates on either side of the
vertical and horizontal meridian points are tested.
3. In this plotting the total deviation is very high compared to the pattern
deviation. It could be because of a cataract or a small pupil or fixation
losses.
4. Asb stands for apostillbs which is an indicator of the brightness of the
stimulus.
5. The pattern standard deviation for this test is 2.98 dB and is not significant.
Section 2 81
QUESTION 39

2. Name 3 causes for such a field defect.
3. What investigations would you recommend to this patient?
4. Comment on the foveal thresh-hold in the 2 eyes.
5. What is the testing strategy used in this patient?
ANSWER
1. Bitemporal hemianopia. Respecting the vertical meridian spliting the
macula.
2. Pituitary tumor, craniopharyngioma and sphenoidal ridge meningioma.
3. Magnetic resonance imaging of the skull. And pituitary harmone analysis
esp serum prolactin, growth harmone and TSH.
4. Foveal treshold in the re is 30dB and LE is 6 dB. LE is reduced because
visual acuity is reduced in the LE.
5. The strategy used is swedish interactive testing algorithm standard format.
Section 2 83
QUESTION 40
1. What does the left eye field show?

2. Is the field reliable in both eyes?
3. What ophthalmic examination would you like to do in this patient-mention
3?
4. Based on the fields in both eyes can you comment on the site of lesion.
5. What is the value in decibles of the brightest stimulus used for this field
testing?
ANSWER
1. The left field shows a temporal island of vision.
2. Both eyes the field charting is reliable because the fixation loss is below
30% false positive and false negatives are below10%.
3. Pupil examination, fundus and intraocular pressure with gonioscopy need
to be done.
4. Since both eyes are affected and field defect does not respect the vertical
meridian the optic nerves in both eyes or extensive bilateral retinal
pathology are the likely sites of lesion.
5. 0 dB.
Section 2 85
QUESTION 41
1. What is the normal location of the blind spot and is it normal in this
patient? Why?
2. What is the size of the stimulus used for plotting this field?
3. Comment on the grey scale reading of the RE field.
4. Name 2 new commercialy available techniques for plotting the visual
fields.
5. Name three causes for generalized reduction in sensitivity of a visual field.
ANSWER
1. The normal location of the blind spot is between 12 and 17 degrees
temporal to fixation 2 degees above and 3 degrees below the horizontal
meridian. In this patient the blind spot is normal in location.
2. The size is goldman size III.
3. The grey scale reading of the right eye field raw data shows a scotoma
extending above the blind spot probably a bjerrum’s scotoma.
4. Blue on yellow perimetry and frequency doubled perimetry are 2 new
commercialy available techniques of perimetry.
5. Small pupils corneal or lenticular opacity and glaucomatous optic nerve
damage are a few causes of generalized reduction in sensitivity.
Section 2 87
QUESTION 42
1. What is the abnormality seen in the scan?

2. How does the speed of sound differ in the aqueous and lens?
3. What does “a” in a-scan stand for?
4. Name 2 causes for the abnormality seen in the scan.
ANSWER
1. The b-scan shows dome shaped elevations in the upper and lower portion
of the scan touching each other in the vitreous cavity. Most likely to be a
choroidal detachment.
2. Speed of sound in solids is more than the speed of sound in liquids.
Speed of sound in lens is 1641m/s aqueous and vitreous is 1532m/s.
3. A stands for amplitude scan.
4. Hypotony due to post surgery and choroidal vascular tumors.
Section 2 89
QUESTION 43
1. Describe the abnormality seen in the scan.

2. What is the reflectivity of the abnormality seen in the upper right scan?
3. What is the anatomic location of the abnormality?
4. Name one investigation that would help in deciding about the management
of this patient.
5. Name the procedure that you would suggest for treating this patient.
ANSWER
1. High reflectivity shadow seen in the vitreoretinal interface with acoustic
shadowing behind.
2. High reflectivity.
3. In the vitreous cavity close to the retina.
4. Dialated pupil fundus examination.
5. Vitrectomy with intraocular foreign body removal.
Section 2 91
QUESTION 44
1. What is the diagnosis based on the b-scan? Give one differential diagnosis.
2. If the abnormal shadow in lower left scan does not move with the
movement of the eye ball what could be the complication that the patient
has developed.
3. What is the reflectivity of the normal vitreous in a scan?
4. What is the frequency of the ultrasound waves used for ophthalmic b-
scanning?
ANSWER
1. Retinal detachment. DD is posterior vitreous detachment. In this case
sinse the abnormal shadow is attached to the optic disc in a funnel shaped
manner it is most likely to be a retinal detachment.
2. Proliferative vitreoretinopathy is the complication of long-standing retinal
detachment that can cause fixed funnel shadow.
3. Normal vitreous is acousticaly no reflective and no shadow is obtained.
4. The frequency used for ophthalmic b-scanning is 8-10 megahertz.
Section 2 93
QUESTION 45
This slide was prepared from a patients corneal scrapping.

1. Identify the organism.
2. What is the staining used?
3. What medium would you use to culture the organism?
4. Name 4 drugs that could be used topicaly to treat such cases.
ANSWER
1. Fungal filaments.
2. No stain has been used. It is a koh mount.
3. Saberouds dextroser agar.
4. Natamycin, amphotericin-B, fluconazole and ketokonazole.
Section 2 95
QUESTION 46
Examine the slide obtained from corneal scrapping of a patient with
blepharitis and corneal ulcer and answer the questions.
1. What is the staining technique used?

2. What is the color of the microbe stained in this slide? Why does it stain
this way?
3. Mention the chemicals and stains used in this staining technique with
their uses.
4. Name 2 microorganisms that stain this way and mention 2 topical
medications effective against them.
ANSWER
1. Grams staining.
2. Blue. It stains blue because the cell wall characteristics of gram-positive
organisms resist decolorization by acetone.
3. Methylene blue is the primary stain,iodine is the mordant that fixes the
methylene blue to the cell wall, acetone is the decolorising agent and
strong carbol fuschin is the counter stain.
4. Streptococci and staphylococci fluoroquinalones like ciprofloxacin and
ofloxacin and erythomycin and chloramphenicol.
Section 2 97
QUESTION 47
This is a slide prepared from the contact lens case of a patient with corneal
ulcer.
1. Name 3 organisms that can stain this way.

2. Which culture medium can be used to differentiate between these 3
organisms?
3. Which is the drug of choice for topicaly treating these patients?
4. Name one protozoa specifically infecting contact lens wearers using home
made saline for disfecting their lenses and the stain used to identify it.
ANSWER
1. Pseudomonas, E. coli and Proteus and Klebsiella (gram-negative rods).
2. Mackonckys agar.
3. Fortified tobramycin.
4. Acanthamoeba calcofour white.
Section 2 99
QUESTION 48

2. What are the causes of reduced vision in this patient?
3. Name 2 important systemic associations causing morbidity to such patients.
4. What is the biochemical basis of this problem?
5. What is the usual mode of inheritance ? If only the eye were to be affected
by such a problem what is the mode of inheritence?
ANSWER
1. Oculocutaneous albinism.
2. Foveal hypoplasia, refractive errors, photophobia and nystagmus
3. Hermansky-Pudlak syndrome, Chediak Higashi syndrome
4. Defective melanin synthesis due to deficiency of enzyme tyrosinase
5. Autosomal recessive. Ocular albinism is X-linked recessive.
Section 2 101
QUESTION 49
1. What is your clinical diagnosis based on the fundus photograph and limb
photo?
2. Name 3 important treatable causes of night blindness?
3. What is the visual field defect you would expect in this patient?
4. What electrophysiological test would you like to do? What is the result in
typical patients?
ANSWER
1. Bardet-Biedl syndrome.
2. Abeta lipoprotinemia, refsum’s disease, gyrate atrophy
3. Ring scotoma.
4. Dark adapted blue flash erg extinguised a and b waves.
Section 2 103
QUESTION 50
1. What is the position of the eyes in primary gaze?

2. What is the position of the eyes in lateral gaze?
3. What is the differential diagnosis based on these findings alone?
4. What test would you like to perform in this patient to reach a final diagnosis?
ANSWER
1. Right hypotropia (left hypertropia)
2. Left hypertropia increasing on right gaze.
3. Left superior oblique palsy and right superior rectus palsy.
4. Bielchowskys head tilt test.
Section 3
Questions 51-75
QUESTION 51
Given below is the additional photographs of the same patient.
1. What are the 3 steps of the Bielschowsky’s test.

2. What is your diagnosis?
3. What is the physiologic basis of the final step of this test.
4. If this patient had this problem from birth what additional tests would
you like to do?
5. How can you identify a similar problem in the other eye?
ANSWER
1. Which eye is hypertropic in primary gaze, hypertropia increases in which
lateral gaze and hypertropia increases in which side head tilt.
2. Left superior oblique palsy.
3. In left head tilt the left eye has to intort. Because of the unopposed action
of the left superior rectus while intorting the left eye in the presence of a
paretic superior oblique which is also supposed to intort the eyeball goes
upwards.
4. Vertical fusional amplitude and family album tomography.
5. Positive head tilt test bilaterally, bilateral inferior oblique overaction,
v- esotropia and bilateral fundus extorsion are signs of bilateral superior
oblique palsy.
Section 3 109
QUESTION 52

2. How will you differentiate an upper motor neuron lesion from a lower
motor neuron lesion?
3. What muscle sequelae will follow in this patient?
4. What investigation would you suggest to follow up the progression or
deterioration of the patient?
5. To prevent muscle sequela what can be done for this patient?
ANSWER
1. Right lateral rectus palsy.
2. Oculocephalic reflex will be preserved in a uppermotor neuron lesion.
3. Left medial rectus overaction, right medial rectus overaction,and
inhibitional palsy of the right lateral rectus.
4. Hess charting.
5. Inject botulinum toxin into the medial rectus of the left eye.
Section 3 111
QUESTION 53
This is the gonioscopy of a 60-year-old asthmatic and hypertensive gentleman
who complained of occasional headaches and gradual painless dimunition
of vision. His iop was 35 mm hg in be.
1. Which angle is being examined.

2. Name 3 findings in the peripheral anterior chamber.
3. Is this angle closed? Give 1 reason.
4. What would be your first 2 steps in managing this eye?
ANSWER
1. Inferior angle.
2. PAS, open angle and increased pigmentation of the TMW.
3. No, the angle is open because the trabecular meshwork can be visualized.
4. Central visual field examination and fundus examination of the disc.
Section 3 113
QUESTION 54
1. What are these plastic shells called?

2. What are they used for?
3. How do you decide which side they can be applied to?
4. What are 2 important uses of the mutiple holes seen?
5. Which is the best method for full cosmetic rehabilitation following
enucleation.
ANSWER
1. Conformers.
2. Maintain the volume and shape of an anophthalmic socket.
3. Notch should be supronasal.
4. Allow secretions to flow out and application of medications.
5. Hydroxyappetite orbital implants or dermis fat grafts with implants in
case of volume deficient sockets.
Section 3 115
QUESTION 55
1. Name this procedure.

2. What is the next stage and what should be the interval between the stages?
3. Name 2 advantages of this form of lid repair.
4. Name 2 drawbacks.
ANSWER
1. Cutler beard technique of lid repair.
2. Release of upper lid and resuturing the bridge to the lower lid tissue after
6 weeks.
3. Large central lid defects can be repaired, better lid movement and better
cosmesis.
4. Large central area devoid of eyelashes, eye has to be closed for 6 weeks.
Section 3 117
QUESTION 56
This patient was seen in the casuality following ocular trauma.
1. Describe the injury.

2. What first aid would you administer?
3. Where would you pass the first suture for the lid wound?
4. Where should the cardinal suture be for the corneoscleral laceration?
5. Name 2 important postoperative instructions to the patient.
ANSWER
1. Penetrating injury with corneoscleral and lid laceration.
2. TT, IV antibiotic and eye patch.
3. Grey line.
4. Limbus.
5. Prolonged steriod therapy and report blurring of vision and photophobia
in the other eye.
Section 3 119
QUESTION 57
This 60-year-old patient presented to the casuality with pain and diminution
of vision following 3 days after cataract surgery. His vision recorded in the
casuality was 1/60.
1. What is the clinical diagnosis?

2. List 2 clinical signs seen in the photograph to support your diagnosis.
3. Name an important investigation you would ask for.
4. What is the standard protocol to treat this eye? Give details.
ANSWER
1. Exogenous endophthalmitis.
2. Hypopyon inflammatory membrane.
3. USG—posterior segment.
4. Intravitreal antibiotics—vancomycin (1 mg/0.1 ml)/ceftazidime (2-3 mg/
0.1 ml) and amikacin 0.2-0.4 mg/0.08 ml.
Section 3 121
QUESTION 58
Examine this fundus photograph of a child 28 weeks gestational age with a
birth weight of 1100 gm. Comment on the following.
1. What instrument has been used to take the photograph?

2. What is the staging of rop in this eye?
3. Is this threshold rop? Give 2 reasons.
4. How will you manage this child at this stage?
5. When will you screen a child for rop?
ANSWER
1. Retcam.
2. Stage 2 ridge.
3. No, this is no threshold rop as it is only stage 2 and there is no plus
disease.
4. Follow up after 2 weeks.
5. 32 weeks gestational age.
Section 3 123
QUESTION 59
Examine the tracing provided and give your interpretation.
1 P100N145
P100
Nicolet
Sensitivity and sweep time per division

1 5.00 uV 25.0 ms 3 5.00 uV 25.0 ms
1 Chan pattern reversal
N75 N75
P100 P100 104.00ms
N145 N145
N75P100 N75P100
N100N145 N100N145 11.09mv
N75 N75
P100 P100
N145 N145
N75P100 N75P100
P100N145 P100N145
1. What kind of stimulus has been used?

2. Name 2 clinical examinations necessary to interpret the site of abnormality.
3. What is the latency for the right eye?
4. What is the amplitude for the left eye?
5. If the fundus is normal, what is the most likely diagnosis for the left eye?
ANSWER
1. Pattern stimulus.
2. Pupillary reflex and fundus examination.
3. Latency for the right eye is 104 milli seconds.
4. The amplitude in the right eye is extinguished and cannot be measured.
Section 3 125
QUESTION 60

2. Name two associations?
3. What do you expect vision in left eye to be if patient is emmetropic?
4. Do you expect the visual field to be affected? Why?
5. Name one clinical condition where this pathology is reversible.
ANSWER
1. Myelinated nerve fiber.
2. Neurofibromatosis.
3. Normal.
4. Yes, opaque nerve fibers will prevent light from reaching photoreceptors
below them.
5. Multiple sclerosis.
Section 3 127
QUESTION 61
Given below is the atropinized retinoscopy from 2/3 meters of a 5-year-old
boy with squint.
Right eye 90° + 5.50d, and 180° + 7.25d.
Left eye 90° + 0.50 and 180° – 0.50 d.
1. What is the subjective correction you would give considering the working
distance? Do not subtract the drug correction.
2. Transpose your prescription.
3. What squint would you expect in this child if it started after the age of
1 year?
4. What movement would you see on doing retinoscopy of the left eye
without any lens in place?
5. What are the signs of neutralization?
ANSWER
1. Re +4.0/+1.75x 90°
Le –2.00/+1.00x180°
2. Re +5.75/-1.75x 180°
Le –1.0/-1.0x90°
3. Accommodative esotropia.
4. With the movement in vertical meridian and against the movement in
horizontal meridian.
5. Movement becomes faster, reflex becomes broader fills the pupil.
Section 3 129
QUESTION 62

2. Mention 3 findings to support your diagnosis.
3. What is clinically significant macular edema? Does this patient have it?
4. Will you treat this patient with laser photocoagulation?
ANSWER
1. Nonproliferative retinopathy.
2. Microaneurysms, hard exudates dot and blot hemorrhages
3. Retinal thickening at or within 500 mm of foveola, hard exudates at or
within 500 mm of foveola if associated with thickening of adjacent retina,
a zone of thickening larger than 1 disc area within 1dd of foveola. Yes,
this patient has CSME.
4. Yes.
Section 3 131
QUESTION 63
This is the fundus fluorescein angiography picture of the same patient on
6 months follow up.
1. What is the abnormality encircled.

2. What features of the abnormality on fundus examination and FFA that
help in making the diagnosis?
3. What are the characteristics of high-risk PDR?
4. What is the wavelength of the laser used for photocoagulation of the
retina.
ANSWER
1. Neovascularization elsewhere.
2. New blood vessels may be flat or elevated from the retinal surface, can
cross major vessels, have arborescent branching pattern and leak profusely
on FFA.
3. NVD greater than 1/4 dd without vit hemorrhage, less extensive NVD
with vitreous hemorrhage, NVE >1/2 dd with vit hemorrhage or pre-
retinal hemorrhage are high-risk characteristics of PDR.
4. 512 nm argon green laser and 832 diode red.
Section 3 133
QUESTION 64
1. What are the findings in the fundus photo and FFA?

2. What is the principle behind fluorescein angiography?
3. What is blood retinal barrier?
4. What is the evidence in the FFA that could be the cause of the abnormality
seen in the disc?
5. How can we know about the glycemic control of this patient in the past
2 months?
ANSWER
1. NVD, hard exudates, dot and blot hemorrhages and extensive areas of
capillary non-perfusion and microaneurysm on FFA.
2. Flourescence is the principle by which a substance absorbs light of longer
wavelength-blue is absorbed and light of longer wavelength–green-
emmited.
3. The outer blood retinal barrier is formed by the tight junctions called
zonula occludens between RPE cells and the inner blood retinal barrier is
formed by the endothelial cells of the retinal blood vessels.
4. Areas of capillary non-perfusion signify areas of hypoxia which could be
the cause of the NVD.
5. By assessing the glycosolated hemoglobin levels in the blood we can know
the patients glycemic control over the past 2 months (HbA1C).
Section 3 135
QUESTION 65
1. Name 4 causes of this abnormality.

2. What are the visual problems likely to be faced by this patient?
3. What treatment can be offered to this patient if his vision is affected grossly
by this problem?
4. What are the complications that the patient might develop because of
this abnormality?
ANSWER
1. Marfan’s syndrome, homocystinuria, trauma and sulfite oxidase deficiency.
2. Monocular diplopia, myopia and irregular lenticular astigmatism with
defective accommodation.
3. Phacoemulsification with Cionni ring placement and IOL in the bag.
4. Pupillary block glaucoma, dislocation of the lens into the a/c or vitreous
by trauma.
Section 3 137
QUESTION 66
1. What is the principle behind this test?

2. How does corneal thickness affect the validity of this test?
3. How do you disinfect this instrument?
4. What is the significance of the red line in the instrument?
5. What is the diameter of the area of contact in the cornea?
ANSWER
1. Principle of applanation according to the imbert fick law.
2. A falsely high reading may be obtained in thicker corneas and a falsey
low reading in thinner corneas esp after lasik.
3. 3% hydrogen peroxide for 5 min,isopropyl alcohol for 5 min or 10%
sodium hypochlorite for 30 min.
4. The red line is aligned with the axis of oblique astigmatisn to get the
mires.
5. 3.06 mm.
Section 3 139
QUESTION 67
1. At what distance this vision chart has to be placed from the patient?
2. What is the use of the white spot?
3. What is the use of the colored circles?
4. How will you use the colored letters? How will you perform this test in
color blind person?
5. Which type of acuity chart is useful for measuring vision of an amblyopic
patient?
ANSWER
1. 6 meters from the patient for a direct chart and above the patients head
for an indirect chart with mirror at 3 meters.
2. For maddox rod testing.
3. Worth 4 dot test.
4. Duochrome test is used to ascertain our final end point of refraction using
the principle of chromatic aberration, since the test depends on the principle
of chromatic abberation it does not require color discrimination and hence
can be useful for the color blind person too.
5. Single optotype charts give better visual cuity than multiple optotype
Snellen charts in amblyopic patients as crowding phenomenon reduces
visual acuity when tested with usual Snellen charts.
Section 3 141
QUESTION 68
1. What is the abnormality seen?

2. Why is the abnormality seen in the left photograph in this shape?
3. Name 2 causes of this condition.
ANSWER
1. NVE with subhyaloid (pre-retinal) hemorrhage.
2. The blood in the subhyaloid space does not clot because it is bound by 2
smooth surfaces. Hence the RBCS separate from the plasma giving rise
to the boat shaped hemorrhage.
3. Diabetic retinopathy, Terson’s sign in increased ICT due to trauma and
subarachnoid hemorrhage.
4. The NVE has to be treated with pan retinal photocoagulation.
Section 3 143
QUESTION 69

2. What is the complication associated with it?
3. What do you expect on gonioscopy of this patient?
ANSWER
1. Essential; iris atrophy.
2. Glaucoma
3. Broad based peripheral anterior synechiae
4. Medical treatment is ineffective. Trabeculectomy or artificial filtering shunts.
Section 3 145
QUESTION 70
A 10-year-old boy complains of defective vision. Pupil examination is normal.
Given below is the fundus photograph.
1. Give 3 differential diagnosis for the fundus finding.

2. What is the major visual complaint that this patient is likely to have?
3. What tests would you perform in this patient?
4. Name one diagnostic test and its finding to support your diagnosis.
ANSWER
1. Stargardt’s disease, cone dystrophy and north carolina dystrophy.
2. Loss of central visual acuity, photophobia and hemaralopia.
3. Color vision examination, family history and FFA.
4. 30 hertz flicker response erg, extinguished a and b waves.
Section 3 147
QUESTION 71
This 25-year-old man sustained injury to the left eye with a tennis ball 2
weeks ago, his anterior segment photograph is given below.
1. What is the shape of the pupil?

2. Name 2 important causes of this condition.
3. How would you treat this condition in this patient.
4. List 5 other problems that you would like to look for in this patient.
ANSWER
1. D-shaped pupil.
2. Blunt trauma and surgery.
3. It can be left alone if it doesn’t cause any cosmetic problem to the patient.
Otherwise a 10/0 prolene mckennel suture can be used to suture the iris.
4. In a patient with blunt trauma we have to look for traumatic iritis,angle
recession, cataract, Berlins edema of macula,vitreous hemorhage, giant
retinal tears and choroidal rupture.
Section 3 149
QUESTION 72
1. Name 3 clinical conditions where this test can be useful.

2. How should this test be done?
3. What are the questions that you would like to ask this patient while doing
this test in sequence?
4. What is the angle subtented by each square at the retina when the chart
is kept at the correct viewing distance?
5. How many degrees of central retina can be assessed with this test?
6. If the patient cannot see the central dot can this test be performed?
ANSWER
1. ARMD,CSR and assessing drug toxicity like chloroquine.
2. At 33 cm cover one eye with his reading glasses patient fixates on the
central dot and looks at the chart.
3. Do you see the central dot. Do you see all four corners while looking at
the central dot,are the lines straight, are any of the squares distorted or
missing.
4. 1 degree.
5. Central 10 degrees.
6. Yes 2 diagonal lines should be drawn to help fixation.
Section 3 151
QUESTION 73
1. What is the principle behind this test?

2. How is the intraocular pressure measured from the reading in the scale?
3. What is differential tonometry?
4. What are the limitations of this test?
5. How is this instrument disinfected?
6. What is pseudofacility?
ANSWER
1. Indentation tonometry with constant area variable force.
2. By looking at the fridenwalds nomogram.
3. When iop is measured with different weights its called differential
tonometry, it helps to overcome false readings due to changes in scleral
rigidity.
4. Scleral rigidity, lying down posture.
5. 70% alcohol or acetone.
6. With increase in iop there is a slight reduction in aqueous production due
to reduction in ultrafiltration that appears as an increase in aqueous
outflow.
Section 3 153
QUESTION 74
This 4-month-old baby brought to the hospital with complaints of not seeing
properly.
1. What history would you like to elicit from parents?

2. Give 3 differential diagnosis for this condition.
3. What examination would you like to do in this child?
4. Would you like to examine the parents why?
5. How will you measure vision in this baby using the fixation pattern?
ANSWER
1. Gestational age, birth weight and use of oxygen in the perinatal period
and family history of eye tumors.
2. Congenital cataract, ROP, PHPV and retinoblastoma.
3. B-scan and fundus examination.
4. Yes. To rule out heriditary form of bilateral retinoblastoma.
5. Central, steady and maintained. CSM fixation pattern.
Section 3 155
QUESTION 75
1. What is the power of various lenses available for this test?

2. What are the characteristics of the image formed?
3. If you want to examine a patient with small pupil what adjustments you
will make?
4. How many circles are there in the Amsler’s chart and what does each
circle signify?
5. Which anatomical landmarks denote the following
a. Equator b. 3 and 9 o’ clock meridian
ANSWER
1. 13d 20d 30d.
2. Real magnified inverted and laterally reversed, formed between the lens
and the observer.
3. Increase IPD, small spot size reduce illumination and use the small pupil
facility.
4. 3 circles. Inner one for equator, middle for ora serrata and third one
between pars plana and pars plicata
5. Ampullae of vortex veins, long ciliary nerves.
Section 4
Questions 76-100
QUESTION 76
1. What is the magnification offered by this instrument?

2. How much of the retina can be examined by using this instrument in a
fully-dialated pupil?
3. What is the depth perception with this instrument?
4. How is distant direct ophthalmoscopy useful?
5. What are the image characteristics with this instrument?
ANSWER
1. 15x.
2. Central 30°. Field of view is 5°.
3. No depth perception due to monocular viewing.
4. At 1 meter it is done to assess the media opacities by parallax.
5. Virtual,magnified erect image.
Section 4 161
QUESTION 77
1. What is the name of the material used to make this stip of paper?
2. What is the length of this paper and what is the use of the notch in it?
3. How will you quantify basal tear secretion and reflex tear secretion?
4. Name the accessory lacrimal glands.
5. What are the normal and abnormal values for this test?
ANSWER
1. Whatman 41 filter paper.
2. 35 mm and the notch is 5 mm from one end for folding the paper prior
to insertion in top the eye.
3. Readings after topical anesthesia of the cul-de-sac is basal tear secretion.
Readings after irritation of the nasal mucosa with a cotton wisp after
anesthesia of the conjunctival sac.
4. Krause and wolfrings glands.
5. Less than 5 mm of wetting of the paper in 5 minutes is abnormal. Above
10 mm of wetting in 5 minutes is normal.
Section 4 163
QUESTION 78
1. Name this instrument.

2. How do you use this instrument?
3. Name two more instruments that can be used for the same purpose.
4. Name two uses of this instrument.
ANSWER
1. Hertels exophthalmometer.
2. Fix base reading, throw light on the cornea read from the ruler in the
prism.
3. Ruler and lourdes scale.
4. To measure and diagnose proptosis and for follow up.
Section 4 165
QUESTION 79
This 25-year-old lady sought consultation for intolerence to contact lens wear.
1. What are the differences between superficial and deep vascularization of

the cornea?
2. Name causes for superficial vascularization of the cornea?
3. What is the probable cause of vascularization in this patient?
4. Can LASIK be suggested as an alternative to c/l in this patient?
ANSWER
1. Superficial vessels are continuous with the conjunctival blood vessels and
are located in the superficial layers of the cornea, whereas the deep vessels
are discontinuous at the limbus and are located at the deep layers of the
cornea-like the stroma.
2. Contact lens wear, foreign body in the cornea, phlyctenular keratitis and
dry eyes.
3. Long-term contact lens wear induced-hypoxia could be the probable
cause.
4. In the presence of extensive vascularization the LASIK flap will bleed and
hence may not be an ideal choice to this patient.
Section 4 167
QUESTION 80
This patient a diabetic for past 5 years underwent laser photocoagulation
elsewhere and complained of sudden diminution of vision after the procedure
in the right eye.
1. What is the most likely cause of drop in vision.

2. What are the various modes of laser PHC used for treatment of diabetic
retinopathy?
3. How does laser treatment work in various stages of diabetic retinopathy?
4. What are the various modes of laser delivery to the retina in diabetic
retinopathy management?
ANSWER
1. In advertant foveal burns could be the cause of sudden diminution of
vision.
2. Focal photocoagulation for NPDR with leaking microaneurysms, grid PHC
for diffuse macular edema and pan retinal photocoagulation for high-risk
PDR.
3. In focal PHC the laser causes closure of the leaking microaneurysm, in
grid PHC the laser stimulates the RPE to resorb the edematous fluid from
the macula and in PRP the laser destroys the hypoxic retina that produces
the vasoformative substances.
4. Laser can be delivered through slit lamp, indirect ophthalmoscope and
endoprode during vitrectomy for photocoagulation of the retina.
Section 4 169
QUESTION 81

2. What are the systemic associations with this ocular problem?
3. At which gestational age do you think this problem started?why?
4. What is the retinal complication of this problem?
ANSWER
1. Typical coloboma of the iris and choroid re.
2. Congenital heart defects, retardation of growth,choanal atresia,
genitourinary abnormalities and ear defects.
3. 5th week of gestation as the choroidal fissure starts closing at this time.
4. Atrophic holes can form at the colobomatous retina and can result in
retinal detachment. Such a detachmnet is very diffcult to treat as there is
no RPE to take up the laser and the coloboma is inaccessible to cryo.
Section 4 171
QUESTION 82
This 8-year-old girl with history of joint pains was sent to the ophthalmologist
for routine examination.
1. What is the abnormality seen?

2. What serological investigation would you like to do in this child ?
3. What are the ocular complications that this child can develop?
4. What is stills disease?
5. How does the number of joints involved and results of serological tests
influence the eye follow up of the patient?
ANSWER
1. Festooned pupil due to posterior synechiae.
2. Rheumatiod factor and antinuclear antibody.
3. Cataract, band-shaped keratopathy and glaucoma.
4. Syatemic onset jca is known as stills disease (lymphadenopathy fever
arthralgia and splenomegaly).
5. Pauciarticular plus ana—3 months, pauciarticula—4 months, polyarticular
ana—6 months, polyarticular—9 months, Still’s disease annually.
Section 4 173
QUESTION 83
1. What are the precautions you would take while doing this procedure?
2. What is the % and the quantity of the dye used in this procedure?
3. How is the dye injected? Why?
4. What is the arm to retina circulation time?
5. How will you distinguish an artery from vein-based on the filling ?
ANSWER
1. Patient should be informed about the procedure and consent form should
be signed, emergency trolley with oxygen, ambu bag, adrenaline, efcorlin,
atropine, deryphylline and lasix must be available. A tray for collecting
vomit should be handy. Renal function must be assessed before the test.
2. 3 ml of 25% or 5ml of 10% or 10 ml of 5% sodium fluorescein should be
used.
3. The injected as a bolus into the antecubital vein because the pictures will
be better this way.
4. 8 seconds is the arm to retina circulation time.
5. Veins show laminar flow.
Section 4 175
QUESTION 84
1. What is the temperature and the pressure for sterilizing operating

instruments in an autoclave?
2. How will you make sure that instruments have been sterilized?
3. What is high speed autoclave?
4. How will you disinfect the operating theater?
5. What is the disadvantage of autoclaving surgical instruments?
6. Name two other methods of sterilizing surgical instruments.
7. What is the difference between disinfection and sterilization?
ANSWER
1. 121 degree at 30 psi for 20 min.
2. By using stips impregnated with Bacillus streatothermophillus and culturing
it after the process or by using indicator strips which change color to
brown.
3. 131°C at 35 psi for 7 min is high speed autoclaving.
4. By fumigating with formaldehyde, UV radation and washing with lysol.
5. Plastic instuments handles will melt at high temp and the tip of sharp
instruments may become blunt.
6. Ethylene tri-oxide, gamma irradiation and hot air oven.
7. By disinfection we destroy vegetative form of disease causing organisms.
By sterilization all the spores and organisms are destroyed. By antiseptic
we inhibit growth of disease causing organisms.
Section 4 177
QUESTION 85

2. Why is the abnormality at this location?
3. What complications can it lead to?
4. How will you manage this problem?
ANSWER
1. Inverse hypopyon or hyperoleon.
2. Silicon oil being lighter than water always flats in the anterior chamber.
3. Silicon oil glaucoma, corneal endothelial cell loss and cataract in phakic
eyes.
4. By removing the silicon oil from the eye through the limbus in aphakic
eyes or by pars plans in phakic eyes before the problem occurs. Once the
silicon oil emulsifies and forms an inverse hypopyon it has to be removed
through the a/c. An andoiridotomy in the 6’o clock position can protect
against a severe pressure elevation prophylactically.
Section 4 179
QUESTION 86
1. What is the abnormality in the fundus photograph?

2. What is the abnormality seen in FFA.
3. Name 3 causes of this abnormality seen in the angiogram.
4. How will you treat the patient?
5. What are the systemic associations of the abnormality seen in fundus
photograph?
ANSWER
1. Angoid streaks.
2. Subretinal neovascularization temporal to the fovea.
3. ARMD, mypoia, choroidal rupture, pohs,angiod streaks.
4. Photocoagulation of the SRNVM or photodynamic therapy using
vitreoporphyrin.
5. Pseudoxanthoma elasticum, Paget’s disease, Ehlers-Danlos syndrome and
hemoglobinopathies.
Section 4 181
QUESTION 87
1. Identify the instrument.

2. What are the uses of this instrument?
3. What is the relationship between the sphere and the cylinder in this
instrument?
4. What is the principle behind usage of this instrument?
ANSWER
1. Jackson’s cross cylinder.
2. The entire spherocylindrical refraction can be performed with this
instrument.
3. The cylinder is twice the sphere and of the opposite sign.
4. Strums conoid. The focal lines fall in front and back of the retina.
Section 4 183
QUESTION 88
1. Where is the irrigation and aspiration connected?

2. What is an indirect symcoe cannula?
3. What are the ways of managing subincisional cortex?
ANSWER
1. The irrigation is connected to the cannula and the aspiration is connected
to the tubing with a 5 cc syinge.
2. When the irrigation and aspiration are reversed its called an indirect symcoe.
3. Using a bimanual approach, or using a j shaped cannula.
Section 4 185
QUESTION 89
This 26-year-old man sustained a RTA and injury to the left side of the face
1 month back. On examination a scar was seen in the lateral orbital rim. His
visual acuity was 6/60 in the left eye.

2. If this problem is unilateral what clinical tests will help you to reach the
diagnosis?
3. What are the causes of this condition in this patient?
4. How could you manage the patient if you had seen him immediately
following the trauma?
ANSWER
1. Traumatic optic neuropathy.
2. Pupil examination for RAPD and color vision.
3. Direct trauma to optic nerve with a fragment of bone, edema of the optic
canal.
4. CT scanning of the orbit to reveal bone spicule on the nerve or edema
has to be done. Then we can plan for surgical management or IV methyl
prednisolone.
Section 4 187
QUESTION 90
Penlight
4 Diopter
base out
prism
LE RE
F F
Adducts Adducts
Normal Normal
Eye Eye
1. What is the use of this test?

2. How is the prism placed in front of the eye?
3. What is the response of the normal eye if both eyes are normal?
4. What is the response of the normal eye if the prism is placed in front of
the abnormal eye?
ANSWER
1. To detect the presence of a suppression scotoma and thus the presence
of a microtropia.
2. Base out.
3. Initialy the eye will move in the other eye will move out then it will move
in for refixating.
4. No movement.
Section 4 189
QUESTION 91
1. Name this investigation.

2. Name 2 principles used for this investigation.
3. What is the use of this investigation?
4. How is the results of this investigation expressed?
5. What is the relationship between pupil size and this investigation?
ANSWER
1. Aberrometry.
2. Hartmann’s chack and tscherning principle.
3. To measure the wave front of the eye and hence the aberrations. From
this information a custum ablation to rectify the refractive error can be
done.
4. Zernickes polynomials.
5. Aberration are always more with a increase in pupil size.
Section 4 191
QUESTION 92
1. What is the procedure?

2. What is the principle behind this procedure?
3. What are the complications of this procedure?
4. How will you customise this procedure depending on the refractive error?
5. What instrument is needed for performing this procedure?
ANSWER
1. Radial keratotomy.
2. The radial cuts relax the central cornea thereby flattening it.
3. Micro perforations in the cornea, unpredictable outcome, regression,
infection and incision extending in to the visual axis.
4. By altering the number and depth of the incisions.
5. Diamond knife with depth guage.
Section 4 193
QUESTION 93
A 55-year-old man came for a routine eye examination and this is the
ophthalmoscopic findings in both eyes.
1. Describe the findings in the disc.

2. What additional information from the patients history and eye examination
you need to confirm your diagnosis?
3. Give 3 differential diagnosis.
4. What is phasing?
5. Name 3 drugs that can be used in this condition?
ANSWER
1. Glaucomatous cupping of the disc with 90% vertical and horizontal and
bayonetting.
2. History of headaches and haloes, family history of glaucoma, IOP and
fields.
3. Physiological cupping, methyl alcohol poisoning and glaucoma.
4. Measurement of IOP at different times of the day in 24 hours is called
phasing and it is used to identify diurnal variation in IOP.
5. Beta blockers like timolol 0.5%, latonoprost and brimonidine.
Section 4 195
QUESTION 94
1. What is this implant made up of?

2. What is pegging?
3. What is the advantage of this material over glass?
4. Mention 2 indications each for enucleation and evisceration.
ANSWER
1. Hydroxy appatite.
2. Drilling a hole in the implant after 6 weeks and putting a prosthesis in to
it is called pegging.
3. It is bio integrated implant as the vasculature grows into the implant there
by making extrusion of the implant a rarity.
4. Enucleation-retinoblastoma and eye donation. Evisceration-endoph-
thalmitis and anterior staphyloma with pain.
Section 4 197
QUESTION 95
Given below is the preoperative and postoperative orbscan of a patient.
1. What does the orbscan measure?

2. What is the difference between the pre and postoperative anterior float?
3. Why is the post LASIK posterior float red in color?
4. What is the depth of tissue ablated for each diopter of refractive error
corrected?
ANSWER
1. Orbscan measures the anterior and posterior curvatures of the cornea
and the thickness.
2. + 0.012 pre op and – 0.012 mm post lasik.
3. Red color indicates steepening of the cornea. If the posterior surface
becomes ectactic it is seen as red.
4. 10 to 12 microns for each diopter of refractive error corrected.
Section 4 199
QUESTION 96
This 45-year-old lady complained of drooping of the eyelid 2 months. An
ice pack test was done and the photograph is given below.
1. What additional history would you like to elicit from the patient?
2. How does the findings of the ice pack test help you in reaching the
diagnosis?
3. Name two drugs that can cause a similar drooping of the eyes in susceptible
individuals.
4. Name one pharmacologic test that would help clinch the diagnosis.
5. What treatment would you offer the patient if the pharmacologic test is
positive?
ANSWER
1. History of diurnal nariation, fatiguability and drug intake.
2. When an ice pack is placed over the orbicularis muscle the neuromuscular
conduction improves and hence a positive test signifies myasthenia.
3. Quinidine, aminoglycoside antibiotics.
4. Tensilon test. 1 mg of edrophonium hydrochloride injected IV will cause
remarkable improvement in symptoms in myasthenic patients.
5. Oral pyridostigmine or neostigmine and oral steroids can be tried in
myasthenic patients.
Section 4 201
QUESTION 97
A 30-year-old man sustained a road traffic accident and complined of
asymmmetry between the two eyes with double vision. The right pupil was
2.5 mm and the left pupil was 4 mm. The left eye lid showed a ptosis of
2 mm. The anisocoria was more in bright light.
1. Could it be a case of Horner’s syndrome in the left eye? Give two reasons.
2. How will you rule out pharmacologic mydriasis as a cause of the anisocoria?
3. What are the slit lamp findings of Adie’s pupil?
4. What is denervation supersensitivity?
ANSWER
1. No, it cannot be a case of left Horner’s syndrome because in Horner’s
syndrome the pupil is constricted and the anisocoria is maximum in dim
light.
2. A pupil dialated due to drugs like atropine, cyclopentolate or tropicamide
will not constrict on application of pilocarpine whereas the pupil dialated
due to a 3rd nerve lesion will constrict to pilocarpine.
3. In Adie’s pupil there will be a vermiform contraction of the pupil and the
pupil will remain constricted even after the lamp is switched of.
4. An Adie’s pupil will constrict with 1/8 conc of pilocarpine solution due to
supersensitivity of the parasympathetic receptors in the sphincter pupillae.
This is known as denervation supersensitivity.
Section 4 203
QUESTION 98 AND 99
SURGICAL PROCEDURE
This patient came to the hospital for diminished vision in his left eye. His
intraocular pressure was 34 mmHg left eye and fundus examination revealed
a 0.8 vertical cupping. Patient underwent combined cataract surgery and
glaucoma surgery.
1. What are the exit routes for the aqeous after a trabeculectomy?
2. How is water tight closure of the fornix based conjunctival flap achieved?
3. Name 2 important causes of postoperative hypotony in this patient.
How will you distinguish between the two?
4. Name 2 important causes of acute elevation of IOP in the immediate
postoperative period. How will you differentiate between them?
5. What are the causes of failure of a glaucoma filtering surgery after 1-
year-postoperative? Name 3 catagories of patients who are more prone
to failure.
6. What measures can you take during the surgery that could help in
preventing late failure of the trabeculectomy surgery?
7. Name 2 non-penetrating anti glaucoma surgical procedures? What is
the advantage of such procedures over conventional trabeculectomy?
8. Name 2 non-surgical managements of a patient not responding
adequately to maximum medical therapy.
9. Where would you place the incisions for phacoemulsification and
trabeculectomy? Why?
10. Where and why would you perform an iridotomy in a patient
undergoing trabeculectomy only?
ANSWER
1. RHE aqeous exits the eye through the cut ends of the Schlemm’s canal,
through the sides of the trabeclecutomy flap in to the subconjunctival
space after a trabeculectomy bypassing the trabecular meshwork.
2. The fornix based conjunctival flap is sutured to the cornea with
10 nylon continuous wing suture.
3. Excessive filteration due to a loose scleral flap suture and conjunctival
button hole. Siedel test will be positive in the case of a conjunctival
button hole.
4. Ciliary block glaucoma due to aqeous misdirection into the vitreous
and pupillary block glaucoma are the causes of a postoperative pressure
elevation. A patent peripheral iridotomy is seen in the former and b-
scan ultrasound reveals pockets of aqeous in the cilliary block glaucoma.
5. Filtering blebs are prone to failure in young patients, patients on topical
antiglaucoma medication for a long time and in patients undergoing
repeat surgeries. The usual cause of failure is sub conjunctival fibrosis of
the filtering bleb and scarring.
6. Use of antimetabolites like mitomycin c and 5 fluorouracil can reduce
the postoperative scarring.
7. Visco cannulostomy and deep sclectomy are 2 non penetrating
antiglaucoma surgeries. Their main advantage is that postoperative
hypotony is avoided with such procedures.
8. Trans scleral cyclophotocoagulation and trans scleral cyclo cryo therapy.
9. The phaco could be done through the clear cornea temporaly and the
trab through the12 o’clock sclera. The advantage is that the 2 incisions
are separated and healing of the phaco incision does not affect the
patency of the trabeculectomy. The other way is to perform both
surgeries through the superior scleral tunnel.
10. The iridotomy has to performed peripheraly and basally just below the
trabeculectomy ostium. This is ensure that the trabeculectomy ostium
does not get occluded by the iris.
Section 4 205
QUESTION 100
INVESTIGATION- RADIOLOGY
This 25-year-old man sustained injury to the left eye while beating an iron
rod with chisle and hammer on examination the patient had perception of
light in the left eye.
L
R
L R
1. What is the diagnosis based on the X-ray and CT scan?

2. How will you manage this patient?
3. What evidences would you look for in the anterior segment slit lamp
examination in a case of retained intraocular foreign body in the retina?
4. Name 3 techniques for localising a foreign body in the eye?
ANSWER
1. Intraorbital foreign body close the left optic nerve.
2. An orbitotomy has to be done and removal of the fb has to be attempted.
3. Corneoscleral perforation, iris hole, cataract, vitreous opacity and anterior
chamber reaction.
4. Sweets technique, beers localiser and ultrasound.
Section 5
Observation
Stations
SLIT LAMP EXAMINATION
Specular Reflection
• First step is to see that the eye pieces are set to zero or your glass power.
• Second step is to swing the illumination and the observation system to 90
degree apart.
• The magnification should be in high mag.
• The width of the slit beam can be just less than the maximum and the
height should be 3 mm.
• The patient is instructed to see straight ahead bisecting the angle formed
between the illumination and observation systems.
• The specular reflection of the endothelial cells is obtained uniocularly
only.
Retro-illumination
• Can be done under any magnification. The slit lamp observation system
and the illumination systems should be co-axial.
• The patient should be instructed to look straight ahead and the illumination
system adjusted slowly to get the red glow from the fundus, in the pupil.
• By moving the joy stick towards the patient the cornea, iris ,anterior lens
surface and posterior lens surface and vitreous opacities can be identified
against the red fundal glow.
Sclerotic Scatter
• Used to identify corneal opacities by using the principle of total internal
reflection. Light is thrown on the temporal limbus in such a way that no
illumination is visible. This is because the light is totally internally-reflected
in between the anterior and posterior surfaces of the cornea. If an opacity
is present in the cornea then it will be illuminated by the light beam
travelling horizontally and internally within the cornea.
Applanation Tonometry
• Explain the procedure to the patient.
• First apply 2 or 4% xylocaine into the conjunctival sac.
• Check if the prism in the tonometer is set at 180.
• Adjust the reading in the tonometer body to read 1.
• Use low magnification.
• Swing the tonometer to in front of the slit lamp and ensure that the prism
is visible with one eye only and is in focus.
• Switch on the cobalt blue filter.

• Use maximum illumination.
• Switch off room lights.
• Gently applanate the cornea without exerting pressure on the lids.
• Instruct the patient not to blink.
• Take the reading by rotating the reading knob untill the mires overlap
each other internally.
• Repeat the reading if too much or too little fluorescein is present with the
right quantity of fluorescein.
• Apply a drop of antibiotic to the patient. Ask nurse to disinfect tonometer
prism with sodium hypochlorite or isopropyl alcohol.
Gonioscopy
• Instill a drop of xylocaine 2 or 4% into the cul-de-sac.
• Inspect the gonioscope to see if its clean and which type is given- single
mirror or 3 mirror.
• Dim the room lights.
• Ask patient to keep the chin in the slit lamp and look straight ashed.
• Set low mag beam horizontal for examining the inferior and superior
angle
• Ask patient to look up
• Apply viscoelastic or ky jelly in to the gonioscope and apply the gonioscope
onto the lower sclera.
• Now ask the patient to gently look straight so that the gonioscope is on
the cornea.
• Rotate the gonio mirror to 12 o’clock to see the inferior angle.
• Be careful to see that the illumination does not fall on the pupil as it will
constrict the pupil and result in an opening up of the narrow angle.
• Record which is the posterior most structure you can see for example
cilliary body grade 4, scleral spur grade 3, trabecular meshwork grade 2
and schwalbes line grade 1.
• Look for abnormal pigmentation, cells, debris, pseudoexfoliation material,
peripheral anterior synechiae, peripheral iridotomy, cyclodialysis cleft and
internal ostium of a trabeculectomy.
• Rotate the mirror 360° gently without letting air bubbles to get entrapped
in between the gonioscope and the cornea. Record your findings.
• Gently remove the gonioscope from the eye by asking the patient to look
up and tilting the upper end of the gonioscope outwards.
Section 5 211
• Clean the eye with a cotton instill a drop of antibiotic into the eye. Clean
the gonioscope.
Retinoscopy
• Greet the patient and explain the procedure.
• Check for dialatation of pupil and cycloplegia.
• Make the patient sit properly and choose your working distance as ½ or
2/3 meter.
• Put on the trial frame on the patient. Ask the patient to fixate on the 6/60
letter on the chart.
• Start with the right eye of the patient sit to the left of the patient and use
your right eye.
• Hold the retinoscope with your right hand with the thumb on the sleeve
to make it vertical or horizontal. Make sure the illumination is adequate
and that the plane mirror is selected.
• Move the streak horizontally twice to check movement. Then rotate it
vertically with your thumb and move the retinoscope by moving your
wrist not your entire hand or body.
• Select the appropriate spherical lens from the trial frame to neutralise the
reflex. Chose the appropriate power, for example a slow moving with
reflex in an aphake start with +9.0.
• Chose the next lenses systematically going for higher powers until
neutralisation is reached.
• Record your horizontal and vertical readings as the power cross.
• Repeat for the other eye by sitting at the right side of the patient for his
left eye and use your left eye for the retinoscopy. Remember to wear
your spectacle correction while doing retinoscopy.
Subjective Refraction
• Ask which language the patient can read well.
• Note the retinoscopy in the power cross form and the working distance.
• Write the new power cross after subtracting the working distance.
• Now start the subjective refraction by choosing the appropriate sphere
and cylider. First find the axis of the cylinder, then refine the cylinder
power with a Jackson’s cross cylinder.
• Remember to fog the patient if you are dealing with a hypermetrope.
That is start with higher plus lenses and reduce to get better vision. In case
of minus powers start with smaller power then increase the power untill
you get the final value.
• Finally, do a duochrome test to confirm your correction.
• If patient is undialated check his near vision.
Index
A C
Aberration 190 Calcific band keratopathy 34
Aberrometry 190 Cannulostomy 204
Acute elevation of IOP 203 Cataract 172
Adie’s pupil 201 Causes of an abnormality in a red eye 43
Age-related macular degeneration 8 Causes of an abnormality in a white eye 43
Amblyopia 28 Causes of reduced vision 99
Amblyopic patient 139 Central serous retinopathy 14
Amsler’s chart 155 Central visual field examination 112
Amsler’s grid test 8 Chromatic aberration 140
Angioid streaks 180 Coloboma of the iris 170
Anisocoria 201 Color blind person 139
Ankylosing spondylitis 44 Colored circles 139
Anterior chamber depth 47 Complication in anterior segment 9
Anterior segment complication 15 Cone dystrophy 146
Anterior segment slit lamp examination Conformers 114
205 Conjunctival autograft 38
Anterior subluxation of lens 28 Corneal blood staining 28
Antimetabolites 204 Corneal opacity 28
Applanation tonometry 209 Corneal scrapping 93, 95
Arm to retina circulation time 173 Corneal ulcer 95, 97
Artificial filtering shunts 144 Corneoscleral laceration 117
Asb 79 Cover test 64
Astigmatism 30 Cutler beard technique 116
Atheromatous ulcer 18 Cystoid macular edema 62
B D
Band-shaped keratopathy 172 ‘D’ shaped pupil 148
Bardet-Biedl syndrome 102 Deep vascularisation of the cornea 165
Basal tear secretion 161 Defective vision 9, 11, 145
Behcet’s disease 44 Dellen 40
Bielschowsky’s head tilt test 104,107 Denervation of cornea 18
Bilateral disc swelling 4 Denervation supersensitivity 202
Bitemporal hemianopia 82 Depth perception 159
Blepharitis 95 Diabetes mellitus 16, 36
Blind spot 85, 86 Diabetic retinopathy 142, 167
Blood retinal barrier 133 Diabetic retinopathy management 167
Blow out fracture 72 Diameter range of soft CL 25
Blunt trauma 148 Diminution of vision 167, 168, 203
Blurring of vision 3, 118 Diplopia 30
Botulinium toxin 110 Disadvantage of autoclaving 175
Disadvantage of pneumatic retinopexy 75 High risk PDR 131

Disinfection and sterilisation 175 High speed autoclave 175
Distant direct ophthalmoscopy 159 Homocystinuria 136
Drooping of the eyelid 199 Horner’s syndrome 202
Drop in vision 167 Hypermetropia 60
Duochrome test 140 Hyperoleon 178
Hypertropia 70
E Hypopyon 44, 178
Hypotony 88
Ehlers-Danlos syndrome 180 Hypotropia 104
Endophthalmitis 30, 44 Hypoxia 166
Enlarged blind spot 4
Enucleation 113, 195
Esotropia 128
I
Evisceration 195 Ice pack test 199
Exogenous endophthalmitis 120 Imbert Fick law 138
Extended wear CL 25 Incisions for phacoemulsification 203
Incisions for trabeculectomy 203
F Indentation tonometry 152
Indirect symcoe cannula 183
Fixation pattern 153 Indocyanine green angiography 58
Fluorescein angiography 58, 59, 133 Intolerence to contact lens wear 165
Foreign body in the eye 166, 205 Intraocular foreign body removal 90
Fornix based conjunctival flap 203 Intraocular pressure 151
Foveal hypoplasia 100 Intraorbital foreign body 206
Foveal threshold 81 Intravitreal antibiotics 120
Friedenwald’s nomogram 152 Intravitreal gas 73
Fuch’s endothelial dystrophy 42 IOL power calculation 35
Fully dilated pupil 159 IOP 47
Fundus examination 112, 124, 131, 154 Iridotomy 203, 204
Fundus fluorescein angiography 131
Fungal filaments 94
J
G Jacksons cross cylinder 182
Joint pains 171
Glaucoma 28, 144, 172, 194 Juvenile chronic arthritis 34
Glaucoma filtering surgery 203
Gonioscopy 210
Grams staining 96
K
Greyscale reading 85 Keratitis medicamentosa 46
Gunderson’s procedure 20 Keratoconus 52
Keratorefractive surgery 51
H
Haploscopic principle 66
L
Head tilt test 108 Laser photocoagulation 167
Herpes zoster 46 Lateral orbital rim 185
Herpes zoster keratitis 42 Lateral rectus palsy 68, 110
Hertels exophthalmometer 164 Lenticular opacity 86
Hess chart 69-71,110 Lower motor neuron lesion 109
Index 215
M Phaco hand piece 78

Phacoemulsification 136
MacConkey’s agar 98 Phasing 193
Macular edema 12, 129 Photocoagulation of the retina 131
Macular holes 76 Photophobia 100, 118
Maddox rod testing 140 Pneumatic retinopexy 75, 76
Malignant hypertension 4 Polypropylene 30
Marfan’s syndrome 136 Posterior corneal elevation 51
Methyl alcohol poisoning 194 Postoperative hypotony 203
Methylene blue 96 Postoperative orbscan 197
Microtropia 188 Preoperative orbscan 197
Mitomycin-C 38 Proptosis 164
Mode of inheritance 99 Pseudoexfoliation 32
Morbidity 99 Pseudofacility 151
Multiple optotype Snellen charts 140 Pseudoxanthoma elasticum 180
Multiple sclerosis 126 Ptosis 201
Muscle sequela 109
Myelinated nerve fibre 126
R
N Radial keratotomy 192
Reduced visual acuity 11
3rd nerve lesion 202 Reduction in sensitivity 85
Neovascular glaucoma 10 Reflex tear secretion 161
Neovascularization 16 Refractive error 197
Night blindness 101 Renal failure 34
Nonproliferative retinopathy 130 Retinal detachment 92
Normal vitreous in a scan 91 Retinal hemorrhage 10, 12
North carolina dystrophy 146 Retinal pigment epithelium 59
NSAIDs 62 Retinal vein occlusion 12
NVE 142 Retinoblastoma 44
Nystagmus 100 Retinoscopy 211
Retro-illumination 209
O Ring scotoma 102
Rubeosis iridis 16
Ocular albinism 100
Ocular coherence tomography 56
Open angle glaucoma 32 S
Optic atrophy 5 Sclectomy 204
Optic nerve damage 86 Sclerotic scatter 209
Orbscan measure 197 Serological investigation 171
Oxygen transmissibility of CL 25 Shallow anterior chamber 48
Siedel test 204
P Silicon oil glaucoma 178
Paget’s disease 180 Single optotype charts 140
Pain and watering 20 Site of lesion 83
Painless diminution of vision 111 Size of the stimulus 85
Pan retinal photocoagulation 168 Slit lamp examination 38, 209
Pattern deviation 79 Small pupils 86
Pegging 195 Specular reflection 209
Penetrating keratoplasty 20, 28, 42 Squint 127
Phaco 204 Stargardts disease 146
Sterilising surgical instruments 175 Unit of oxygen transmissibility 25

Steroid therapy 118 Upper motor neuron lesion 109
Still’s disease 171, 172 Uveitis 34
Stimulus 123
Sub-incisional cortex 183 V
Subjective refraction 211
Sulfite oxidase deficiency 136 Vascularisation 165
Sulphur hexa fluoride 74 Vermiform contraction 202
Superficial punctate keratitis 46 Vision chart 139
Superficial vascularisation of the cornea Visual acuity 140, 185
Visual field defect 3, 101
165
Visual problem 29, 135
Superior oblique palsy 70, 108
Vitrectomy 56
Surface ectoderm 36
Vitreomacular traction 61
Swedish interactive testing algorithm
Vitreous cavity 90
82
Volume deficient sockets 114
Sweets technique 206
W
T Whatman 41 filter paper 162
Temporal island of vision 84 White lesions in fundus photograph 7
Tensilon test 200 White spot 139
Total deviation 79 With pain diminution of vision 119
Toxoplasmosis 44
Trabeculectomy 144, 203 X
Trauma 136, 185
Traumatic optic neuropathy 186 X-linked recessive 100
Trypan blue dye 36
Z
U Zernickes polynomials 190
UGH syndrome 30 Zonula occludens 134

Osce Oftalmología

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Objectively Structured

Amar Agarwal MS FRCS FRCOPHTH

Objectively Structured Clinical Examination (OSCE) in Ophthalmology

First Edition: 2005

Typeset at JPBMP typesetting unit

Index ................................................................................................... 213

SLIT LAMP PHOTOGRAPHS

VIDEO OF SURGICAL PROCEDURES

MICROBIOLOGY AND PATHOLOGY SLIDES AND SPECIMEN

1. Identify this condition.

1. Identify this condition.

1. Identify this condition.

1. What is the diagnosis?

1. What is anterior segment complication of this condition?

1. Describe the findings in these photographs?

1. What surgical procedure has been done?

1. Evaluate the fit in top photograph.

1. Of the four photographs, which is the best fit?

QUESTION 12 (CONTD... Q. 11)

1. Give three differential diagnosis for this picture?

1. What is the diagnosis?

1. What is the diagnosis?

1. What is the diagnosis?

1. What are the causes of such conditions in a 40 years old man?

1. What refractive error is likely to be caused by this lesion?

1. What is the vertical line seen in the cornea called?

1. What is the diagnosis?

1. What is the anterior chamber depth?

1. What is the principle behind this investigation?

1. What does red color in the upper left map indicate?

1. What is this investigation?

ANSWER 26 (OCT MAC HOLE)

1. What is the abnormality seen in the picture?

ANSWER 27 (OCT SRNVM)

1. What is the black dome shaped area due to?

ANSWER (OCT CSR)

1. What is this condition?

Cover RE; observe LE

LE moves LE does not move

Tropia Cover LE; observe RE

Uncover RE; observe LE RE moves RE does not move

Be move No movement Tropia No tropia

Be move No movement Movement No movement

Rec Sup Ob in. Rec Sup Ob in.

Rect int Ob. sup. Ob. sup. Rect int

Ob. sup. Ob. sup.

Green before left eye Green before right eye

1. What is the color of glasses worn before the test eye?

Rec Sup Ob in. Rec Sup Ob in.

Rect int Ob. sup. Ob. sup. Rect int

Ob. sup. Ob. sup.

Luthra surgical works

1. What is the position of the right eye in primary gaze?

Rec Sup Ob in. Rec Sup Ob in.

Rect int Ob. sup. Ob. sup. Rect int

Ob. sup. Ob. sup.

Luthra surgical works

1. What is the diagnosis?

Rec Sup Ob in. Rec Sup Ob in.

Rect int Ob. sup. Ob. sup. Rect int

Ob. sup. Ob. sup.

Luthra surgical works

1. What is the diagnosis?