Objective structured practical question (ospe)

Objective Structured Practical Question (OSPE)

Subject: Ophthalmology

According to the course curriculum of Post graduate ophthalmology

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AUTHOR:Dr Md Anisur Rahman Anjum.MBBS (Dhaka Medical College). DO (Dhaka University) FCPS (EYE)Associate ProfessorNational Institute of OphthalmologyDhaka, Bangladesh. Chamber: Mojibunnessa Eye HospitalHouse: 18 Road: 6. Dhanmondi, Dhaka, 1205. Bangladesh.Email: anjumk38dmc@gmail.comCell: 01711-832397

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OSPE:01

anjumk38dmc@gmail.com

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Question

• Your patient needs +2.00 D to see distance clearly. However, he can tolerate up to +4.00D without getting blurred distance vision. His cycloplegic refraction is +6.00D sphere. What are the values in diopter of his?

1) Absolute hypermetropia? 2) Manifest hypermetropia? 3) Facultative hypermetropia? 4) Latent hypermetropia?

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Answer

1) Absolute hypermetropia = + 2.00D (absolute hypermetropia is defined as the least amount of plus lenses needed for clear vision without cycloplegia)

2) Manifest hypermetropia = + 4.00D (manifest hypermetropia is defined as without cylcoplegia, the most plus correction that can be tolerated without blurring of vision)

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Answer (Contd)

3) Facultative hypermetropia = + 2.00D (facultative hypermetropia is defined as the difference between absolute and manifest hypermetropia + 4.00D - + 2.00D = + 2.00 D)

4) Latent hypermetropia = + 2.00 D (latent hypermetropia is defined as the difference between manifest hypermetropia and hypermetropia measured with cycloplegia + 6.00D - + 4.00D = + 2.00D)

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OSPE:02

Question

• The following patients have 6/6 vision (with spectacle correction where needed) and have no cataract. The results of the refraction and keratometry are as shown below:

• Patient A: Refraction: OD -2.50D OS plano • Average Keratometry: OD 44.50D OS 44.50D

• Patient B: Refraction: OD -2.50D OS plano • Average Keratometry: OD 44.50D OS 42.00D

• a. What types of myopia does i) patient A and ii) patient B have?

• b. Which patient is likely to get aniseikonia if the myopia were corrected with glasses?

ANSWER

ANS=1) Patient a axial myopia. Pt b. refractive myopia. 3+3=6

ANS= 2) Patient B. The use of glass in refractive myopia is associated with diminution of image. Whereas in axial myopia as in patient A the size of the image is not altered.=4

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OSPE:03

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A stenopaic slit showed is used to test the eye of a patient with astigmatism.

When the slit is held at position like above fig, the patient requires a +3.00D sphere to see clearly and when the slit is held at position like below fig, the patient requires a +2.00D sphere to see clearly.

• a. Draw the power cross for this patient.

• b. What is the prescription needed to correct this patient's vision.

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ANSWER

• Ans b• +3.00/-1.00 Dcyl 90• OR• +2.00/+1.00 Dcyl 180

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OSPE:04

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Question

• A 40 year-old myopic woman is recently prescribed soft contact lenses for the first time. She returned two weeks later and complains that her reading vision is not as good as with her glasses. Retest shows her visual acuity to be 6/6 in both eyes with the contact lenses and the lenses were of the right prescription and well-fitted. Why does she have problem reading with her contact lenses but not with her glasses?

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Answer

• The patient is pre-presbyopic. Myopes require less accommodation with glasses than contact lenses. In addition, the prismatic effect (base-in prism) offered by the concave glasses assist convergence during reading.

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OSPE:05

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Question

A patient comes for refractive surgery with keratometry readings of 43.0 D/42.0 D and a

manifest refraction of -9.5 D. If LASIK were performed, what would be the postoperative

average keratometry reading?

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Answer

The formula is keratometry change = (0.8 X refractive change).

Here, the keratometry change = 0.8 x 9.5 D = 7.6 so the calculated final postoperative average is K = {(43.0 D + 42 .0 D)÷2 }- 7.6 D = 34.9 D.

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OSPE:06

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Question

• Referring to the LogMAR visual acuity chart.

1) What does LogMAR stand for?

2) What is the distance between the two letters in each row?

3) What is the distance between adjacent rows of letters?

4) What is the LogMAR value for a visual acuity of: • i. 6/60 and

ii. 6/6?

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Answer

1) Logarithm of the Minimal Angle of Resolution.

It is also called the Bailey-Lovie chart.

2) The distance between the letters in each row is equal to one letter width of the same row.

3) The distance between adjacent row is equal to the height of the letters in the smaller row i.e the letters below.

4) 1.0 for 6/60 and 0 for 6/6.

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OSPE:07

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QUESTION

A patient has a visual acuity of 6/6 in both eyes while wearing glasses with the following prescriptions:

• OD -1.00/-0.50 X 90 OS -2.25 / -1.75 X 180

• The keratometry reveals the following results: • OD 7.85 mm along 1800 (43.00D)

7.85 mm along 900 (43.00D) • OS 7.80 mm along 1800 (43.25D)

7.50 mm along 900 (45.00D)

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QUESTION

1. Which structure contributes to the astigmatism in the

a. right eye? = 3b. left eye? = 3 2. If the patient were to wear spherical hard

contact lenses, which eye will see better? =4

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ANSWER

• 1a) the lens• 1b) the cornea.• 2) The left eye

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OSPE:08

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Question

• A patient with bilateral anterior and intermediate uveitis is suspected of having sarcoidosis. There are no conjunctival or eyelid granuloma. Chest x- ray shows no abnormalities. serum angiotensin-converting enzyme (ACE) level is normal.

1) Which investigation will confirm the diagnosis?

2) Which is the best single screening test for sarcoidosis?

3) What is the characteristic of Heerfordt syndrome (uveoparotid fever)?

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Answer

1) High-resolution computed tomographic scan of the chest.

2) X-Ray chest.

3) Heerfordt syndrome (uveoparotid fever),is characterized by

uveitis,

parotitis,

fever, and

facial nerve palsyanjumk38dmc@gmail.com

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Explanation

• The definitive diagnosis of sarcoidosis relies on histologic confirmation of noncaseating granulomata. A chest radiograph is probably the best single screening test for sarcoidosis, as it reveals abnormal results in approximately 90% of the patients with active Disease. Thin-cut spiral computed tomographic( CT) imaging is a more sensitive imaging modality and may be particularly valuable in the patient with a normal-appearing chest radiograph in whom there remains a high clinical suspicion for disease. In such cases, parenchymal, mediastinal, and hilar structures with distinctive CT patterns highly suggestive for sarcoidosis may lead to the diagnosis. Although serum ACE and lysozyme levels may be abnormally elevated neither is diagnostic nor specific.

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• Source: AAO Volume=9. Page= 171-177.

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OSPE:09

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Question

A 40 – year old lady presented with severe headache, examination revels 6/6 vision both eyes with papilloedema.

1) What are the investigations you have to do to diagnosed the patient.

2) What are the MRI findings of pseudotumor cerebri and ICSOL?

3) Mention the CSF findings of PTC?

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Answer

• 1)

i. MRI/CT brain

ii. LP CSF findings

iii. RBS/FBS & 2 hrs after breakfast

iv. Measure BP

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Answer

i. PTC → Normal/ slit like ventricle.

ii. ICSOL → Definite mass. Ventricular enlargement.

CSF pressure raised.

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OSPE:10

Scenario

• A lady at childbearing age (overweight) came to you with the complaints of Headache, Dizziness, nausea, and vomiting but typically there are no alterations of consciousness or higher cognitive function. Tinnitus, or a "rushing" sound in the ears, transient visual obscurations, general blurriness, and intermittent horizontal diplopia. These symptoms tend to worsen in association with Valsalva maneuvers and changes in posture. Reports of ocular pain, particularly with extreme eye movements, have also been noted.

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Question

i. What is your diagnosis? === 1

ii. What are the other D/D? write 2 === 2

iii. What will you get in fundsoscopic examination? Write 3 ========== 3

iv. What will be the most common field defect? ==================== 1

v. Write 3 criteria.============== 3

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Answer

i. Pseudotumor cerebri

ii. a)Migraine, b) intracranial tumor.

iii. a) bilaterally swollen, edematous optic nerves consistent with true papilledema. b) striations within the nerve fiber layer, c) blurring of the superior and inferior margins of the neural rim, d) Chronic papilledema may result in atrophy of the nerve head,

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Answer

4) enlarged blind spot, ( followed by a nasal deficit, typically affecting the inferior quadrants. Other field losses seen in PTC include arcuate defects, nasal step, generalized constriction, and least commonly, cecocentral scotoma.)

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Answer

5) Pseudotumor cerebri is a syndrome disorder defined clinically by four criteria:

(1) elevated intracranial pressure as demonstrated by lumbar puncture;

(2) normal cerebral anatomy, as demonstrated by neuroradiographic evaluation;

(3) normal cerebrospinal fluid composition; and

(4) signs and symptoms of increased intracranial pressure, including papilledema.

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OSPE:11

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Question

• A new born baby came to you with Central corneal opacity present at birth, iridocorneal adhesions, cataract, elevated lOP, and cardiac abnormalities.

1) What may be the possible diagnosis?

2) What are the D/D?

3) Is the condition usually bilateral or unilateral?

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Answer

1) . Peters anomaly

i. congenital hereditary endothelial dystrophy (CHED)

ii. congenital glaucoma

iii. Peters plus.

3) About 80% of the case is bilateral.

Explanation

Peters plus refers to the same finding associated with limb dwarfism. CHED does not have elevated lOP. Corneal opacity and iridocorneal adhesions are not consistent with congenital glaucoma alone

• Peter’s anomaly is a central corneal opacity present at birth that may be associated with variable degrees of iridocorneal adhesion extending from the region of the iris collarette to the border of the opacity. Approximately 80% of cases are bilateral. Associated ocular abnormalities are present in approximately 50% of cases. Ocular abnormalities include keratolenticular touch, cataract, congenital glaucoma, microcornea, aniridia. Characteristic histopathologic findings in Peter’s anomaly include a localized absence of the corneal endothelium and Descemet's membrane beneath the area of opacity.

• Peter’s anomaly has been associated with systemic malformations in up to 60% of patients. These abnormalities include developmental delay, heart defects, external ear abnormalities, hearing loss, CNS deficits, spinal defects, gastrointestinal and genitourinary defects, facial clefts, and skeletal anomalies. Although systemic malformations may be associated with genetically transmitted syndromes (trisomy 13- \5, Peters-plus syndrome, Kivlin syndrome, Pfeiffer syndrome), these associations are the exception rather than the rule.

• Most cases of Peter’s anomaly occur sporadically; however, both autosomal recessive and dominant modes of inheritance have been reported.

• Source: AAO Volume=8. Page 256, 257, 258, 261

OSPE:12

Question

• A Patient complaints of bilateral floaters, distortion of central vision, which is wax and wane over many months. The external eye is often white and uninflamed.

1) What is your diagnosis?

2) What are the systemic diseases be associated?

3) What findings will you get?

4) What ocular investigation will you do?

5) What are the causes of vision loss?

Answer

• 1) Intermediate uveitis/Pars planitis.• 2)

ii. Sarcoidosis.

iii. Vitreous cells

iv. Vitreous snow ball

v. Vitreous snow banking

Answer

ii. OCT

iii. Chronic CME

iv. Macular hole formation

OSPE:13

Question

• A 25 years lady came to you with the complaints of transient visual obscurations last only a few seconds and are characterized by a ‘greying out’ or ‘darkening’ of vision in one or both eyes, often precipitated by changes in posture.

2) Write 2 D/D.

3) Write 2 investigations.

Answer

1) Papilloedema.

i. Anterior ischaemic optic neuropathy in patients with giant cell arteritis.

ii. Migraine.

iii. MRI

iv. Superficial temporal artery biopsy

• Source: Jack, J, Kanski chapter: 19 Neuro-ophthalmology (migraine)

OSPE:14

Question

You received a call from obstetrics emergency ward to see a hypertensive 40 yrs old lady carrying for 7 months who gave history of repeated convulsions followed by loss of vision. You found VA –PL in B/E, Fundus & pupil reactions are normal in B/E.

1) -What is the possibility?

2) -What might be the underlying causes?

3) -What investigations you suggests?

Answer

1) Possibility

i. —Cortical blindness

2) Causes

ii. Eclampsia leading to occipital infraction.

iii. Hypertensive aneurismal rupture leading to occipital haemorrhage

Answer

3) The investigations:

I. -CT scan of brain---for haemorrhage

II. -MRI of brain--------for infraction

III. -Urinary protein------for eclampsia

IV. -Total platelet count and or FDP( fibrin degradation product)------------for DIC (platelet count will decrease & FDP will increase)

Explanation

• Explanation---The lady has eclampsic attack leading to DIC (dessiminated intravascular coagulation)or hypertensive aneurismal rupture causing occipital infraction or haemorrhage respectively.

OSPE:15

Question

• Q-4 A middle aged female referred to neuro ophthalmology clinic by an ophthalmologist who noted mild papilloedema both eye with recent onset of severe headache which was not relieved by any analgesics and a month of treatment with adequate Acemox tablets , repeated lumber puncture prior to which CT scan and MRI revealed nothing except ventriculomegaly ( gave no impression of ICSOL or Duct stenosis)

1) What might be the possibilities? Mention 2

2) What else investigations do you want to do?-------4

3) What may be the treatment?--------2

Answer

1) Possibilities are-

i. Cerebral venous sinus thrombosis

ii. Obstructive hydrocephalus following TB meningitis

2) Other Investigations

iii. MRV

iv. CSF study

v. MT test

vi. CBC with ESR

Answer

3) Treatment----

i. Refer to Neurologist.

ii. Heparin or Warferrin therapy.

iii. Anti TB drug 9 m regimen with steroid, sometimes shunt surgery may be required in difficult cases.

Explanation:

• Explanation: The clinical features mimics this is a case of Idiopathic Intracranial HTN but it denies when not responding to any of its treatments. Again it denies ICSOL or Acueduct stenosis since CT scan and MRI revealed nothing except ventriculomegaly, incase of IIH the ventricles become slit like but never dilated . The dilemma in diagnosis of such cases of middle aged women with nonresponding headache commonly present with cerebral venous sinus thrombosis which is confirmed by MRV(magnetic resonance venogram) that shows segmentation of blood column in cerebral sinuses. The treat is by Low molecular weight heparin or warferrin. Another possibility in the context of our country is obstructive hydrocephalus following TB meningitis.

OSPE:16

Scenario & Question

12 year-old boy whose parents are seeking a second opinion for his poor vision in the right eye noted 3 years ago. He has been followed up by an ophthalmologist who initially started him on a course of antibiotics presuming it was toxoplasmosis. ..

On Examination: VAR 6/18. VAL=6/6p Ocular Motility= Full in all gaze. No RAPD IOP 12 mmHg OD/ 13 mmHg OS

Fundus R/E. Fundus=L/E

Question

1) What your diagnosis? = 2

2) What is the prognosis.=3

3) How vision deteriorate? Mention two causes.=5

Answer

1) Best (vitelliform) macular dystrophy.

2) Five stages Pre-vitelliform Vitelliform Pseudohypopyon Vitelliruptive Atrophic

Answer

• 3) Prognosis is reasonably good until the 5th decade after which visual acuity declines in one or both eyes.

• 4) Any two• SRNVM, • Scarring.• geographic atrophy

OSPE:17

This 30 year-old HIV positive man was referred by his physician because of this appearance in the left retina. He has no history of diabetes

mellitus or hypertension.

Question

1) What is the main differential diagnosis?

2) Which HIV patient is at risk of developing this condition?

3) How would differentiate the conditions mentioned in a.?

4) What other conditions can give rise to the above fundal appearance?

Answer

1) The picture shows a whitish lesion. The main differential diagnosis, given the history, is between HIV retinopathy and cytomegalovirus (CMV) retinopathy.

2) Depleted CD4+ lymphocyte count is the most common risk factor for developing ocular manifestation of AIDS. The incidence with decreased CD4+ counts.

Answer

3) HIV retinopathy is usually multifocal, posterior to the equator and less than one disc diameter. The patient has no visual complaints and the lesions may fade after several weeks. The white lesion in HIV retinopathy is caused by microvasculopathy (cotton-wool spots). The vasculopathy may be caused by occlusion due to deposition of the immune-complex or abnormal endothelial cells.

Answer

In contrast patient with CMV retinopathy tends to complain of floaters and the lesion progresses rapidly without treatment causing retinal haemorrhages and necrosis. Suspicious lesions should be observed over a few weeks to document any enlargement.

Answer

4) The following conditions may give rise to a whitish retinal lesion or cotton wool spots:

diabetes mellitus Hypertension collagen vascular diseases such as SLE retinal vein occlusion retinal artery occlusion chest trauma in Purtscher's retinopathy Anaemia leukaemia

OSPE:18

Color fundus photograph shows inferotemporal retinal vein occlusion, retinal periphlebitis and macular edema

Question

• A man of 25 year old (normotensive, non diabetic, non smoker & non alcoholic) came to you with the complaints of sudden loss of vision. He has also given history of repeated attacks of dimness of vision at morning and recover it after a short time. But this time vision loss is persisting.

2) What is the hallmark of the disease?

3) Write 3 cause of vision loss.

4) In FFA, how will you differentiate active and chronic phase?

5) Write 3 D/D?

Answer

1) Vasculitis retine/ Eale’s disease.

2) Recurrent vitreous hemorrhage is the hall mark of this disease.

i. Vitreous Hemorrhage.

ii. Macular ischemia and

iii. traction macular detachment are associated with poor visual outcome

Answer

4. In cases of active retinal periphlebitis, staining of the veins can be seen in the early venous phase with extravasations of dye in the late phase. In the healed stage, only staining of the vessel wall occurs without any leak in the late venous phase.

i. Coat’s disease

ii. PDR

iii. Sickle cell retinopathy

iv. Syphilitic neuroretinitis.

(SOURCE: PAHWA : 78)

OSPE:19

Question

1. What are the 2 positive finding in this picture? =2

2. How many area will be non perfuse before develop this feature? =1

3. What is your diagnosis? =2

4. What other 2 features you may get in this stage?=2

5. What other general and ocular investigation will you perform?=2

6. If you do FFA what positive finding will you get in late phase?=1

Answer

1= 2i. NVD.

ii. Dot and blot hemorrhage

2. More than one quarter of the retina to be non-perfuse before develop this feature. =1

3. PDR= 2

4. NVE, New vessels in the iris = 2

5. RBS. Glycosylated Hb OCT. FFA.= 2

6. hyperfluorescence during the later stages =1

OSPE:20

Question

• A patient with sudden onset of severe headache, 6th nerve palsy, and a bitemporal visual field defect.

1) The most likely diagnosis is?

2) Write 2 D/D.

3) Mention one investigation

4) Is this a medical emergency?

Answer

1) pituitary apoplexy

i. ruptured ophthalmic artery aneurysm

ii. meningeal carcinomatosis

iii. multiple sclerosis.

3) MRI

4) Yes

• Source: AAO Volume = 5. Page = 162, 163, 164. 346. 347

Explanation

• Sudden loss of vision, headache, and ocular motor nerve palsies occur with rapid expansion of a pituitary tumor into the suprasellar and cavernous sinus regions. Prompt neuroimaging and emergency management are essential in these cases.

OSPE:21

• This 75 year-old man presented to the eye casualty with a one week history of distorted left vision. His visual acuity was 6/18 in the left eye with the above posterior segment appearance. He had no history of hypertension or diabetes mellitus.

1) What is the most likely diagnosis? =2

2) What is the main cause of vision loss in this patient.=3

3) In some other disease vision may reduced in the same manner. Mention 3.

4) What are the risk factors of this condition? Mention 4.= 2

• 1 ARMD• 2 SRNVM

1) Age is the major risk factor.

2) Race. Late ARM is more common in Caucasians than other races, despite a similar prevalence of early ARMD.

3) Heredity. Family history is important.

4) Smoking

5. Hypertension and other cardiovascular risk factors are likely to be associated.

6. Dietary factors. High fat intake and obesity may promote AMD, with high antioxidant intake having a protective effect in some groups (see below).

7. Other factors such as cataract surgery, blue iris colour, high sunlight exposure, and female gender are suspected, but their influence remains less certain.

OSPE:22

Scenario

A man 35 year old executive of a multinational company. Normotensive, non smoker & non diabetic, came to with the complaints of sudden dimness of vision right eye.

O/E VAR = 6/12 improves with +1.00 Dsph

VAL 6/6 unaided.

Pupillary reaction normal.

Slit lamp examination= NAD.

Question

1) What may be the diagnosis?

2) What finding will you get by ophthalmoscope exam? Mention 2

3) What is the natural course of the disease?

Answer

1) CSCR

A round or oval detachment of the sensory retina is present at the macula • The subretinal fluid may be clear (particularly in early lesions), turbid or fibrinous, and precipitates may be present on the posterior retinal surface. • One or more abnormal depigmented RPE foci (sometimes small PEDs) of variable size may be visible within the neurosensory detachment. • Small patches of RPE atrophy and hyperplasia elsewhere in the posterior pole may indicate the site of previous lesions.

Answer

• 3) • a) Spontaneous resolution.• b) Chronic• c) Bullous CSCR

(Source Kanski)

OSPE:23

anjumk38dmc@gmail.com 109

The imaging is carried out on a patient who suffers from branch retinal vein occlusion.

04/11/2023

Answer the following questions:

1) What is this imaging technique?

2) What is the diagnosis (F stands for fovea)?

3) Write 3 predisposing factors of CRVO

4) Write 2 vision threatening complications

Answer:

• 1) OCT================= 2• 2) CMO=================2• 3)

a) Age ==================1

b)Hypertension ============1

c)Hyperlipidaemia.==========1

d) Diabetes mellitus =========1

e) Oral contraceptive pill.===== 0.5

f) Raised intraocular pressure == 0.5

g) Smoking. ============== 0.5

Answer

• 4) • a) Chronic macular edema ======= 1.5• b) Neovascularization.========== 1.5

OSPE:24

Scenario: This is a fundus photograph of 60 – year old male with blurring of vision.

Please observe the photograph and answer the following questions.

Q . 1Write 4 important positive findings in this photograph.

Question 2. Mention 3 differential diagnosis.

Question 3.• Write 1) 2 systemic & 2) 2 ocular investigations

to confirm the diagnosis• 1)• a.• b.• 2)• a• b04/11/2023 117anjumk38dmc@gmail.com

Marking Scheme

Question: 1. (any 4)

Write 4 important clinical findings,

a . New vessels at elsewhere (NVE) --- 1

b. Multiple dot-blot hemorrhage -------1

c . Multiple hard exudate-----------------1

d) Laser scars ------------------------------1

e. Arterial attenuation --------------------0.5

• Question: 2. Mention 3 D/D. ( 1 X 3 =3)• a. Proliferative diabetic retinopathy (PDR) • b. Pre- Proliferative diabetic retinopathy

(PPDR)• c. Central vein occlusion (CRVO)

Question 3.• Write 2 systemic & 2 ocular investigations to

confirm the diagnosis• 1) ( 0.5x2= 1)• a) Blood Sugar. Fasting & 2 hrs after breakfast/

• b) HbA1C

• 2) (1x2 = 2)

a) Fundus Fluorescence angiography (FFA)

b) Optical Coherence Tomography. (OCT)04/11/2023 120anjumk38dmc@gmail.com

OSPE:25

Question

• This is a fundus photograph of 65 year- old lady, who is suffering from central visual loss for last few days,

• Q 1. What is your diagnosis?• Q 2. What are the cause? Mention 3• Q 3. Name 4 lesion with similar appearance• Q 4 What are the investigation you do?

Answer

1) Macular Hole.

i. Idiopathic

ii. High Myopia

iii. Blunt Ocular trauma.

Answer

3) Lesions with a similar appearance

a) Pseudo hole in a macular epiretinal membrane.

b) Lamellar hole resulting from an abortive process of macular hole formation or in long-standing severe CMO.

c) Foveal pseudo cyst, typically idiopathic; in at least some patients may correspond to stage 1 macular hole.

d) Vitreomacular traction syndrome.

e) Solar retinopathy.

f) Macular micromole

Answer

i. The Watzke–Allen test.

ii. OCT.

iii. FA

iv. Amsler grid

(Source: Jack J Kanski)

04/11/2023 anjumk38dmc@gmail.com 127GOOD LUCK

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