The document outlines various examination procedures and assessments for ocular conditions, including diagnosing rhabdomyosarcoma, performing the Schirmer test, and taking patient histories related to corneal opacities and recurrent uveitis. It also covers practical examination techniques such as retinoscopy and cataract surgery preparations, along with the importance of eye donation. Specific case examples illustrate the interpretation of test results, necessary preoperative precautions, and management strategies for different ophthalmic conditions.

1. Objective Structured Practical
Examination
Dr Md Anisur Rahman (Anjum)
Professor & Head of the Department
Dhaka Medical College. Dhaka

2. OSPE: 1
Rapidly progressive unilateral proptosis is
usual, Average age of onset is 7 years. The
tumour is derived from undifferentiated
mesenchymal cells. Various genetic
predispositions have been identified, including
variants of the RB1 gene.

3. Question
1) What is the probable diagnosis?
2) What is the most common site in the orbit?
3) Which type is the worse prognosis?
4) Which is the most confirmatory diagnosis?

4. Answer
1) Rhabdomyosarcoma
2) Most commonly superonasal or superior orbit
3) Alveolar
4) Incisional biopsy followed by histopathology
• Kanski 8th edition p 109

5. OSPE: 2
Do the Schirmer test 2 & write down your
interpretation

6. 1) Excess tears are delicately dried. If topical
anaesthesia is applied the excess should be
removed from the inferior fornix with filter
paper.

7. 2) The filter paper is folded 5 mm from one end
and inserted at the junction of the middle and
outer third of the lower lid, taking care not to
touch the cornea or lashes.

8. 3) The patient is asked to keep the eyes gently
closed.
4) After 5 minutes the filter paper is removed
and the amount of wetting from the fold
measured.

9. Interpretation: Less than 10 mm of wetting
after 5 minutes without anaesthesia or less than
6 mm with anaesthesia is considered abnormal.
• Kanski 8th edition p 124

10. OSPE 3
A patient came to you with corneal opacity.
What history should you take from that patient
mention with explanation for the relevant
histories?

11. Answer
• History of onset: Age of onset. If early onset
best possible treatment could not help
satisfactorily because of amblyopia
• History of trauma: If so, there may be cataract,
retain foreign body in presence trauma. And B-
Scan should be done before surgery

12. • H/O Associated pain, redness, watering,
discharge to exclude any corneal ulcer,
aphakic/pseudophakic bullous keratopathy
• H/O past surgeries

13. • H/O associated frequent change of glass
keratoconus
• H/O associated systemic problem
Hyperlipidaemia/Hypercalcemia
• Sankara Nethralaya 124

14. OSPE: 4. History taking R.P
1) Age of onset of symptoms.
2) Duration of night blindness.
3) Duration of progressive loss of visual field.
4) Duration of dimness of vision . Is it
progressive?
5) Family history of R.P.
Wednesday, February 05,
2014
14anjumk38dmc@gmail.com

15. 6) H/O consanguinity.
7) H/O trauma.
8) H/O drug intake.
9) H/O hearing disorder, ataxia, nystagmus.
10)H/O mental retardation.

16. History taking R.P
11)H/O heart disease.
12)H/O hypogenitalism, obesity, polydactyly.
13)H/O diarrhea, skeletal deformity.
Wednesday, February 05,
2014
16anjumk38dmc@gmail.com

17. OSPE=5
Q: History taking of a patient suffering from
recurrent uveitis
A: Following points to be noted during history
taking:
19 FEB 2014 17anjumk38dmc@gmail.com

18. 1) PATIENT DETAILS:
1) Age: Juvenile rheumatoid arthritis (JRA) is
common in patients less than 15 years.
2) Sex: JRA is common in females, HLA – B 27
associated uveitis in males. (but during
history taking you should not asked about
gender)

19. 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.
19 FEB 2014 19anjumk38dmc@gmail.com

20. 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.
19 FEB 2014 20anjumk38dmc@gmail.com

21. H/O exposure/ IV drug abuse/ blood
transfusions.
H/O skin lesions (HZO, Psoriasis)
Details of prior systemic treatment.

22. OSPE: 6
When performing cycloplegic retinoscopy on an
anxious 7-year-old boy, you notice that the
central reflex shows with movement while the
peripheral reflex shows against movement.

23. Question
1) What is the most likely physiological cause?
2) Why there are different central and peripheral
reflexes?
3) If it is physiological how will you overcome
of it?
4) What is the most likely pathological cause?

24. Answer
1) Spherical aberration
2) The periphery of the human lens is more curved
than the center, so the incoming light rays show
increased refraction compared with the light rays
that strike the central lens. In retinoscopy, this
can result in the appearance of different central
and peripheral reflexes.

25. Answer
3) Concentrate on the central light reflex when
performing retinoscopy.
4) Keratoconus
• (AAO Vol 3 p 207)

26. OSPE: 7
• You are planning cataract surgery to achieve
emmetropia for a patient with the following
measurements:
• Refraction: -3.00 +2.00 x 120
• K: 42.50 D/42.75 D @ 120deg

27. Question
1) Which IOL will you prefer to achieve
emmetropia?
2) Give one reason in favour of your IOL choice
3) What are the options to correct astigmatism
during cataract surgery? Mention 2

28. Answer
1) Mono focal
2) The astigmatism is due to cataractous lens
3) .
a) toric lens implants
b) relaxing incisions

29. OSPE: 8
 Motivate a person for eye donation

30. 1 Greetings
2 Eye donation is donating one’s eye after his/her
death
3 Only corneal blind people are benefited from
donated eye
4 Anyone can donate eyes irrespective of
•Age
•Gender
•Blood group
5 The cornea should be removed as early as
possible after death (6 hr)

31. 6 Eyes of donated person can save vision of 2
corneal blind person
7 Donated eye is not for sale
8 Help regarding registration eye donor
9 The donor name will be remembered with respect
by the recipient and their family forever
10 Thank’s

32. OSPE: 9
A 60 years old male patient having uneventful
phacoemulsification with PC- IOL
implantation under topical anesthesia in his
right eye. Prepare a discharge certificate for
the patient.

33. Identificat
ion of the
patient
Name
Age 0.50
Gender 0.25
Address 0.50
Mobile no 0.25
Operation
Note
Date & time 0.50
Name of surgery 0.50
Name of anesthesia 0.50
Name of surgeon 0.50

34. Post operative
findings
Visual acuity 1.00
Anterior segment 1.00
Posterior segment 0.50
Post operative
treatment
Topical antibiotic 0.50
Topical steroid 0.50
Advice No water to eye 0.25
Use dark glass 0.25
Regular use of medicine 0.25
Any problem come to doctor 0.25
Follow up 0.25

35. Identification of
certificate
preparatory
Signature with date 0.50
Name of the doctor with
designation
0.50
Seal of the department 0.50

36. OSPE: 10
A 45 years school teacher having – 2.50
diopter myopia in both eyes and using the
same specs for last 20 years comfortably. Now
come to you for difficulties in reading. Do
retinoscopy at 2/3rd meter & give specs.

37. 01 Greetings
02 Visual acuity Unaided
Pin hole
With existing specs
03 Setting trial
frame
04 Occlude one eye
05 Check
retinoscope

38. 06 Retinoscopy with –
1.00 DS lens
Subjective test
6.a Horizontal meridian
6.b Vertical meridian
7.1 Distance with – 2.50 DS
7.2 Near with add + 1.50 DS
08 Ocular motility
09 Pupillary reaction
10 Proper replacing of
used instruments
11 Thank’s
07

39. OSPE: 11
• A patient of 70 year came to you with ARC (B/E)
R>L for surgery. He came with some medicine which
he is taking for last 5 to 7 years for his different
systemic diseases. You found the medicine are
Metformin 500 twice daily and an adrenergic
antagonists 0.8mg once daily.

40. QUESTION
• A) Now what precaution (preoperative) should you
take for cataract surgery?
• B) What complication may arise during surgery?
• C) How will you overcome of it?

41. A) What precaution (preoperative) should you take for
cataract surgery?
• a).Control DM
• b) Maximum dilatation of the pupil as far as can even
with atropine 1% eye drop

42. • B) What complication may arise during surgery?
a) Pupil may constrict during cataract surgery.
b) The iris may billow and prolapsed through the
incision.
c) The risk of capsule rupture and vitreous loss is
increased.

43. C) How will you overcome of it?
Strategies for management include the
a) Use of Healon 5,
b) preoperative pupillary dilatation with atropine,
c) intracameral epinephrine,
d) iris hooks, and
e) low aspiration flow rates.

44. OSPE: 12
What is the use of this
spectacle?

45. Ptosis props which are used to lift droopy
eyelid

46. OSPE: 13
A B C

47. QUESTION
a
i. How far should the Amsler's chart be placed in
front of the patients?
ii. How many degree(s) does each square subtend in
the macula when placed in the recommended
position?

48. • b.
i. What is the advantage of chart b over chart a?
ii. What is the advantage of chart c over chart a?

49. ANSWER
a)
i. The chart is placed 30 cm from the patient
ii. 1 degree

50. b)
• Chart b contains two diagonal lines, that cross at the
central black point. In patient who can not see the
black spot because of central scotoma, the lines help
to maintain fixation and allows the patient to outline
the limits of scotoma.

51. • The red lines on a black background in chart c is
useful for patient with neuro-logical disorder such as
optic nerve or chiasmal lesion or toxic amblyopia

52. OSPE: 14
 H/O DOUBLE VISION

53. 1) Greetings & self introduction
2) Whether double vision is monocular or binocular
3) Direction of double vision: whether the diplopia is
horizontal,
vertical or
torsional.

54. 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.
5) Ask for diurnal variability and fatigability of
diplopia

55. 6) 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,

56. 7) Underlying systemic illness:
 hypertension,
 diabetes,
 cerebrovascular disease,
 cardiac atherosclerotic disease
 multiple sclerosis.
8) Thank’s to patient

57. OSPE: 15
For the detection of ROP you have to dilate the pupil
of pre mature infant with 2.5% Phenylephrine and
0.75% Tropicamide, but which is commercially not
available
Prepare above concentration with the supplied
materials

58. CHECK LIST
1) Discard 2 ml from the tropicamide
2) Take 1 ml from phenylephrine
3) Mix the phenylephrine with tropicamide
4) Discard disposals

59. MARK DISTRIBUTION
Discard 2 ml from the tropicamide--------------------3.0
• Take 1 ml from phenylephrine----------------------3.0
• Mix the phenylephrine with tropicamide-----------3.0
• Discard disposals--------------------------------------1.0