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

Objective Structured Practical
Question (OSPE)
Subject: Ophthalmology
According to the course curriculum of
Bangladesh College of Physician &
Surgeon (BCPS)
Wednesday, July 16, 2014 1anjumk38dmc@gmail.com

AUTHOR:
Dr Md Anisur Rahman Anjum.
MBBS (Dhaka Medical College). DO (Dhaka
University) FCPS (EYE)
Associate Professor
National Institute of Ophthalmology
Dhaka, Bangladesh.
Chamber: Mojibunnessa Eye Hospital
House: 18 Road: 6. Dhanmondi, Dhaka, 1205.
Bangladesh.
Email: anjumk38dmc@gmail.com
Cell: 01711-832397

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Question
 A 42-year old lady presented with intermittent eye aches.
She has shallow anterior chamber in both eyes. Her unaided
distant visual acuity 6/6 in OU & her near vision N5 with
+1.25 DS in OU. Her anterior segment appeared normal on
Slit-Lamp examination. For proper management:
1) Mention 3 relevant clinical tests= 3
2) Mention 1 important investigation for anterior segment = 1
3) Name 3 differential diagnosis.= 3
4) Mention 3 treatment options = 3

Answer
1) a) Measurement of IOP. b) Gonioscopy. c) Examination of
ONH & Peripapillary Nerve Fiber Layer.
2) UBM/ AS-OCT
3)
i. Primary Angle Closure Suspect (PACS)
ii. Primary Angle Closure (PAC)
iii. Primary Angle Closure Glaucoma(PACG)
4)
i. Anti-glaucoma drugs/ Pilocarpine 2%
ii. Laser Peripheral Iridotomy (LPI)
iii. Trabeculectomy
•

Wednesday, July 16, 2014 anjumk38dmc@gmail.com 6
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2

Question
• An 80-year-old man presents with poor vision in his
right eye with sudden onset of pain and conjunctival
hyperemia. The examination reveals an lOP of 45 mm
Hg with a prominent cell and flare reaction without
keratic precipitates, a dense cataract, and an open
anterior chamber angle.
1) What is the most likely diagnosis?
2) Write 3 D/D.
3) Mention 2 treatment

Answer
1) Phacolytic glaucoma
2) .
i. phacoantigenic glaucoma
ii. ICE syndrome
iii. Fuchs heterochromic iridocyclitis.
3) Medications to control the lOP should be used
immediately, definitive therapy requires cataract
extraction.

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

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

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Question
Who is more prone to develop glaucoma &
who is the least
Patient a) has IOP >23.75 to ≤ 25.75 mmHg
and CCT > 555 to ≤ 588 µm.
patient b) has mean IOP 21.to 23.75 mmHg
but CCT ≤ 555 µm
patient c) vertical C/D ratio ≥ 0.50 CCT ≤ 555
µm

Question
Mention one corneal diseases where IOP is
usually below 10 mmHg

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

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Question
An 11-year-old patient presents with red, itchy eyes. On
examination, gray, jellylike limbal nodules with vascular
cores are seen.
Q:1 This is suggestive of what diagnosis?
Q: 2 Write two D/Ds?
Q: 3 What is the name of limbal nodule?
Q: 4 Over treatment of this patient may cause a vision
threatening condition, Mention its name.
Q: 5 Parents of this is patient always very much worried.
What advice will you give to them. Mention one advice.

Check list
1) Vernal keratoconjunctivitis
2) Any two
phlyctenular keratoconjunctivitis
atopic keratoconjunctivitis
superior limbic keratoconjunctivitis
3) Horner-Trantas dots.
4) Glaucoma/POAG.
5) It is a self limiting disease and will cure after
teen age.

Marks Distribution
1) Vernal keratoconjunctivitis --------------------- 2
2) Any two --------------------------------- 2x1.5 = 3
phlyctenular keratoconjunctivitis
atopic keratoconjunctivitis
superior limbic keratoconjunctivitis
3) Horner-Trantas dots.----------------------------- 1
4) Glaucoma/POAG. ------------------------------- 2
5) It is a self limiting disease and will cure after
teen age. ----------------------------------- 1 + 1 = 2

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

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Question
This is the Humphrey visual field of a 67 year-old
woman.
 a. What type of perimetry is a Humphrey field
analyser? = 2
 b. What does the total deviation measure? = 2
 c. What is the pattern deviation? =2
 d. What does the visual field show? =1
 e. List three conditions which may give this field
defect. =3.

Answer
a. Humphrey field analyser is a static automated
perimetry.
b. The total deviation measures the difference (in db)
between the patient's threshold values and that of the
age-corrected values.
c. The pattern deviation adjusts the total deviation for
any shift in the patient's overall sensitivity. This
allows localised area of field loss to be clearly
demonstrated.

Answer
d. Superior arcuate scotoma.
e.
i. open angle glaucoma with inferior loss of
arcuate nerve fibre layer
ii. optic disc pit
iii. inferior branch retinal vein occlusion

Explanation
• a. Humphrey field analyser is a static
automated perimetry.
(In this test, the patient maintains fixation on a
central target and the computer randomly presents
a brief (about 0.2 seconds) and non-moving ie.
static light stimulus at different loci throughout
the visual field. The intensity of the light stimulus
that the patient can see is then recorded.)
• b. The total deviation measures the difference
(in db) between the patient's threshold
values and that of the age-corrected values.

Explanation
c. The pattern deviation adjusts the total deviation for any
shift in the patient's overall sensitivity. This allows
localised area of field loss to be clearly demonstrated.
(Many conditions other than glaucoma can cause poor vision
for eg. cataract or corneal oedema. Therefore, to find out how
much of a patient’s relative insensitivity to light is due to
glaucoma rather than to something else, it is important to
"subtract out" these other factors. This can be done because
these others conditions tend to produce a similar pattern of
diffuse visual field loss, while glaucoma tends to produce
localized areas of visual field loss.)

Explanation
 d. Superior arcuate scotoma.
 e.
i. open angle glaucoma with inferior loss of arcuate
nerve fibre layer
ii. optic disc pit
iii. inferior branch retinal vein occlusion
(Visual field should not be interpreted without reference to
ocular examination. An arcuate scotoma can occur in other
conditions other than open angle glaucoma as mentioned
above)

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Question
1) What are the advantages of this perimetry
over Humphrey perimetry?
2) What are the advantages of Humphry
perimetry over Goldman perimetry?
3) What do the numbers 1-4 mean?
4) What do the numbers I-IV mean?
5) What abnormalities can be seen in this visual
field?

Answer
1) The main advantages are:
i. The visual field can extend beyond 30 degree.
ii. Stimuli has different size.
2
i. No examiner bias.
ii. Constant monitoring of fixation.
iii. Automated re-testing of abnormal points.
iv. Computer software for analysis.

Answer
3)
They are the intensities of the stimuli.
4)
They are the sizes of the stimuli.
5)
Nasal steep and baring of the blind spot.
These features are suggestive of glaucoma.

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Give a possible cause for the following
field defects.

Answer
A) The visual field shows bilateral altitudinal
field defect.
Possible causes include:
bilateral ischaemic optic neuropathy (arteritic
or non-arteritic)
bilateral superior hemi-retinal artery occlusion
bilateral superior hemi-retinal vein occlusion

Answer
B) The visual field shows bilateral constricted
visual fields.
Possible causes include:
retinitis pigmentosa
bilateral dense laser pan-photocoagulation
advanced glaucoma
 C) The visual field shows a left congruous
horizontal wedge-shaped field defect. It is
seen in lesion of the right lateral geniculate
nucleus such as cerebrovascular accident

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This patient underwent an uncomplicated trabeculectomy. When seen
in the clinic three week later, the intraocular pressure measured 27 mm
Hg and the slit-lamp appearance is as shown below.
1) What is the diagnosis?
2) What is responsible for
this appearance?

Answer
1) The picture shows a smooth dome shaped
elevated cyst. This is typical of a Tenon’s
cyst. Encysted bleb,
7/9/20143939Wednesday, July 16, 2014
1) This is caused by an adhesion between the
episclera and Tenon’s capsule so that the
aqueous is trapped and not drained.

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17
• This is the slit lamp
view of an eye.

QUESTION
1.What is the positive finding in this case? (any 2)
2. What is your diagnosis?
3. Is it an ocular emergency?
4. What may be the treatment?
5. Is the fellow eye needs any treatment?
6. If yes mention of it.

ANSWER
1)
 Ciliary congestion
 Mid dilated pupil, vertically oval.
 Cornea hazy
2) Angle closure glaucoma.
3) Yes
4) Treatment is surgical, but first reduced IOP with Tab
Acetazolamide and Mannitol inj. And then go for P, I or
trabeculectomy according to synechia.
5) Yes
6) Pilocarpine 2% eye drop 4 times in a day or prophylactic PI

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Question
1) Name the printout.
2) Describe RNLF Thickness maps?
3) What are the abnormalities in RNFL Deviation
maps?
4) Describe TSNIT Graphs.
5) What is NFI & what does it indicate?
6) Mention 2 additional relevant investigations to
confirm your diagnosis.

Answer
1) GDx VCC Printout for RNFL Analysis of both eyes
= 1
2) Absence of warm colors (Red & Yellow) in both
eyes more in left eye indicating thinning/loss of
RNFL = 2
3) Appearance of square pixels in superior & inferior
quadrants of both eyes. = 2

Answer
4)
I. Double hump patterns of TSNIT Graphs are absent.
=1
• II. Graphs are flat.=0.5
• III. inferior humps are more flat. =0.5

Answer
5) Nerve fiver indicator, It’s a Global index ranging
from 1- 100.
1-30 indicates normal RNFL Thickness,
31-50 indicates Borderline &
51-100 indicates Thinning of RNFL. = 1
6)
• Digital Optic Disc Photography. = 1
• SAP (HVFA/Octopus VFA). =1

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Question
• Q no 1 What are the disc findings present
here?
• Q no 2 Write the provisional diagnosis depend
upon findings.
• Q no 3 Write the name of investigations for
clinical diagnosis.

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

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

Answer
Answer no 3
• CCT
• VF
• OCT
• HRT

Marks distribution
One for each correct answer
• Q no 1 = 4
• Q no 2 = 3
• Q no 3 = 3

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

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OSPE=2. History taking of Diplopia
1 Whether double vision is monocular or
binocular.
(Causes of monocular diplopia → cataract,
astigmatism, corneal scars, keratoconus, tear
film irregularity, sublaxated lens, large or
sector iridectomy, malingering)
 If binocular → ask whether the diplopia is
horizontal, vertical or torsional.

Ask the patient in which direction of gaze is the
diplopia worse→ right, left, up, down, right and
up, right and down, left and up, left and down, or
distance or near.
3) Ask for diurnal variability and fatigability of
diplopia suggestive of myasthenia gravis.
4) Detailed history about mode of onset, duration of
onset, associated pain, history of strabismus in
childhood, history of trauma, neurological
symptoms such as dysphagia or weakness,
Wednesday, July
16, 2014
61anjumk38dmc@gmail.com

Underlying systemic illness such as
hypertension, diabetes, cerebrovascular
disease, cardiac atherosclerotic disease and
multiple sclerosis.
6) History of smoking or alcohol intake should
be elicited.
Wednesday, July 16,
2014

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4

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

Answer
1) Greetings & self introduction---------------------------
0.25 + 0.25= 0.50
2) Whether double vision is monocular or binocular.----
--------------- 0.50
3) Direction of double vision: whether the diplopia is
horizontal, vertical or torsional.
4) Ask the patient in which direction of gaze the
diplopia is worse→ right, left, up, down, right and
up, right and down, left and up, left and down, or
distance or near.

Answer
5) Ask for diurnal variability and fatigability of
diplopia.
6) Detailed history about :
i. mode of onset,
ii. duration of onset,
iii. associated pain,
iv. history of strabismus in childhood,
v. history of trauma,
vi. neurological symptoms such as dysphagia or
weakness,

Answer
7) Underlying systemic illness:
i. hypertension,
ii. diabetes,
iii. cerebrovascular disease,
iv. cardiac atherosclerotic disease
v. multiple sclerosis.
8) History of smoking or alcohol intake should be
elicited.

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5

History taking of a patient suffering from recurrent uveitis
• Following points to be noted during history
taking:
1) PATIENT DETAILS:
Age: Juvenile rheumatoid arthritis (JRA) is
common in patients less than 15 years.
Sex: JRA is common in females, HLA – B 27
associated uveitis in males. (but during
history taking you should not asked about
gender)
Wednesday, July 16,
2014

2) OCULAR HISTORY:
Is the disease unilateral or bilateral ?
When was the first attack?
When was the last/current attack?
What was the approximate frequency of the
attacks between the first and the last attack?
Details of prior ocular treatment.
Any previous history of rise IOP or use any
antiglaucoma agents.

3) SYSTEMIC HISTORY:
 H/O arthritis or low backache (JRA, HLA –B27 related
uveitis).
 H/O fever or respiratory symptoms, gastro-intestinal,
neurological symptoms, genital lesions.
 H/O DM, HTN, TB.
 H/O exposure/ IV drug abuse/ blood transfusions.
 H/O skin lesions (HZO, Psoriasis)
 Details of prior systemic treatment.

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

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

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

Question
1) Is this MRI scan a T1 weighted or a T2
weighted images?
2) What are the advantages of MRI scan over
CT scan in brain imaging?
3) What abnormalities are present?
4) What is the likely diagnosis?

Answer
1) T2-weighted MRI.
(This is shown by the high signal of the CSF
within the ventricles. In MRI scan of the
brain, T1-weighted image is useful for
demonstrating anatomical details whereas T2
excellent pathology)

2) The advantages of MRI over CT scan of the brain
include:
i. Non-ionising radiation
ii. Excellent soft tissue contrast
iii. Multiplanar images (axial, sagittal and coronal)
iv. No artefact from the bone and is especially
useful for posterior fossa imaging.

C) High signal lesions within the periventricular
white matter of both cerebral hemispheres
• (These represent multiple plaques of
demyelination see figure below, these plaques
have high water content and therefore appear
white on T2-weighted images.)

D) Multiple sclerosis.
Optic neuritis.

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ANSWER
 Coronal plane
F.B in the left orbital floor.
The following 3 feature may be present
 restricted upgaze
 enopthalmos
 hypoanaesthesia over the left check

T1 weighted & T2 weighted

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

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Question
• Convert the following prescriptions to + or - cylinder
notation and state the type of astigmatism which is
present in each
1) +4.00 / -1.50 x 70
2) +1.25 / -3.00 x 90
3) PL / +1.50 x 45
4) -2.00 / +2.00 x 50
5) - 1.75 / -2.00 x 135

Answer
 a. + 4.00 / - 1.50 x 70 = + 2.50 / + 1.50 x 160 ;
compound hypermetropic astigmatism.
 b. + 1.25 / - 3.00 x 90 = - 1.75 / + 3.00 x 180 ; mixed
astigmatism.
 c. PL / + 1.50 x 45 = -1.50 / - 1.50 x 135 ; simple
hypermetropia astigmatism.
 d. - 2.00 / + 2.00 x 50 = PL / - 2.00 x 140 ; simple
myopic astigmatism.
 e. - 1.75 / - 2.00 x 135 = - 3.75 / + 2.00 x 45 ;
compound myopic astigmatism.

ANSWER
 Compound astigmatism occurs when the two principal
meridians of an eye are either both hypermetropic ie.
compound hypermetropic astigmatism or both myopic ie.
compound myopic astigmatism.
 Mixed astigmatism occurs when one principal meridian is
hypermetropic and the other myopia.
 Simple astigmatism occurs when one principal meridian
of the eye is emmetropia and the other myopia ie. simple
myopic astigmatism or hypermetropic ie. simple
hypermetropic astigmatism.

ANSWER

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Question
• Eight weeks after a left cataract extraction and
implant, your patient has the following keratometry:
• 40.00 @90
44.00 @180
1) What is the power and axis of cylinder required to
correct the post-operative astigmatism?
2) If a tight radially placed suture is present, in which
meridian would you most likely to find it?

Answer
1) There is a 4D difference between the two meridians.
So the required cylinder correction is either:
- 4.00 X 90 or
+ 4.00 X180
2) The tight suture is at 1800 and need to be removed.

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

Scenario
 The right conjunctiva showed dilated vessels .
 The visual acuity VAR= 6/12 & VAL= 6/6.
 IOP 40 mm of Hg in R/E & 18 mm of Hg in L/E
 Gonioscopy showed blood in the right trabecular
meshwork
 Fundoscopy= NAD
 The proptosis is non-tender to palpation.
 Bruit can be heard with the bell of a stethoscope
when the eye was closed.

Question
1) What is the most likely diagnosis?
2) What is the gold standard for confirming the
diagnosis.
3) What are the mechanisms of raised intraocular
pressure in this condition?
4) Is this a life-threatening condition?
5) What are the treatment modalities for this
condition?

Answer
1) Direct carotid-cavernous fistula secondary to blunt
trauma is the most likely diagnosis.
2) Cerebral angiogram is the gold standard for
confirming the diagnosis.(The patient will undergo
the investigation under neurosurgical supervision.)
3) Usually it is not a life-threatening condition.
4) The outflow facility is disturbed due to elevation of
the episcleral venous pressure.
5) Wait for spontaneous resolution, if not surgery is the
treatment of choice.

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

Wednesday, July 16, 2014 anjumk38dmc@gmail.com 101THANK YOU

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

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