Objective Structured Practical Examination

Prof Md ANISUR RAHMANPROF & HEAD OF THE DEPARTMENT

(OPHTHALMOLOGY)DHAKA MEDICAL COLLEGE. DHAKA

OSPE: 1A 20 year old student complaints frequent changes of

his spectacles for last 5 year with progressive

unsatisfactory visual outcome. Now his BCVA in R/E

6/12 with – 3.00 DS / - 4.50 DC 20 & L/E 6/36 with –

5.00 DS / - 7.50 DC 140. About 10 years back his

vision was 6/6 in both eyes.

1) What is your diagnosis?

2) Enumerate 2 differential diagnosis

3) Mention 4 signs with name of used instruments

4) Mention 2 clinical tests for confirming the diagnosis

This OSPE question was made by a cornea specialist

but the answer key was wrong

1) Keratoconus 2

2) D/D (any two) 1 x 2 = 2

– Keratoglobus

– Refractive error

– Pellucid Marginal Degeneration

3) Signs (Any 4) (0.5 x 2 x 4= 4)– Direct ophthalmoscope- oil droplet reflex– Retinoscope – scissors reflex– Slit lamp – Vogt striae & Fleischer ring– Torch - Rizuti sign

Clinical investigations (any two) 1 x 2

– Corneal topography

– Pantacam

– Pachymetry

OSPE: 2Supplied vial containing 500 mg of Inj. Ceftazidime.

Make 0.2 mg in 0.1 ml preparation with supplied

materials for intravitreal injection. (with commentary)

• FOLLOWING THINGS ARE NEEDED 

a. Inj Ceftazidime 500mg vial

b. Gloves

c. 5 ml syringe

d. 1 ml syringe

e. Water for injection

1 Wearing of the gloves

2 Add 5mL water for injection with 5 cc

syringe

3 Mixing with shaking

4 Take 1 ml & add 4 ml of D/W

5 Mixing with shaking

6 Take 0.1 ml in tuberculin syringe

7 Discard disposable into basket

8 De-wearing of gloves

OSPE: 3. Which of the following series correctly depicts the relative duration of drug action?

1) atropine>homatropine>scopolamine>cyclopentolate

>tropicamide

2) atropine>scopolamine>homatropine>cyclopentolate

>tropicamide

3) cyclopentolate>tropicamide>scopolamine>homatrop

ine>atropine

4)homatropine>cyclopentolate>tropicamide>scopolami

ne>atropine

5)homatropine>atropine>scopolamine>cyclopentolate>t

ropicamide

Answer is: b.

The duration of action of atropine is 7-14 days,

scopolamine is 4-7 days, homatropine is 3 days,

cyclopentolate is 2 days, and tropicamide is 4-6

hours.

(source: AAO Vol: 2. Page: 413)

Q.1. What are the pictures of?

Q.2. What is the possible diagnosis?

Q.3. Write down 3 associated findings.

Q: 4. What is about VA?

Q.1. What are the pictures of?

A: Iris transillumination defect

Q.2. What is the possible diagnosis?

A: Albinism

Q.3. Write down 3 associated findings / signsA: Nystagmus Foveal hypoplasia Hypopigmentation of fundus High refractive error AmblyopiaQ: 4 < 6/60

On performing fundus biomicroscopy, this was seen.

OSPE: 5

Q.1. What is it?

Q. 2 What may be the early symptom? Mention one

Q.3. What is the diagnosis?

Q.4. Write down 2 causes?

Q.1. What is it? A: Weiss ring

Q.2. What is the diagnosis? A: Post vit detachment

Q.3. Write down 2 causes? A: Trauma, Myopia, Old age

OSPE: 6. H/O DOUBLE VISION

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.

5) Ask for diurnal variability and fatigability of

diplopia

6) Detailed history about :

• mode of onset,

• duration of onset,

• associated pain,

• history of strabismus in childhood,

7) history of trauma,

8) neurological symptoms such as dysphagia or

weakness,

9) Underlying systemic illness:

a. hypertension,

b. diabetes,

10)cerebrovascular disease,

11) cardiac atherosclerotic disease

12)multiple sclerosis.

13)History of smoking or alcohol intake should be

elicited.

OSPE: 7. OCTThis is OCT macular protocol of a 30 years old man

who came with the complaint of blurred vision for 2

weeks.

1) What is the positive findings here?

2) What is your diagnosis?

3) What is its basic mechanism?

4) Write 2 treatment options.

5) Write 2 natural course

A

Separation of RPE from bruchs membrane

An optically empty space in between them.

B. Serous PED

C. Reduction of hydraulic conductivity of a thickened

& dysfunctional bruchs membrane.

D.

• Any two

i. Observation

ii. Intra vitreal Anti-VEGF

iii. Combined Anti-VEGF & PDT.

E. Any two

i. Persistence with atrophy & decrease vision

ii. Resolution with geographical atrophy with visual

loss

iii. RPE tear

iv. Develop CNV in 1/3rd eye.

OSPE: 8A man of 55 year old is in service, came to you with

the complaints of progressive dimness of vision right

eye for last 2 year. On examination you found that he

is suffering from grade 3 Age related cataract right

eye visual acuity is 6/60. Left eye is aphakic and his

BCVA of left eye if 6/12 N6.Now you have to counsel

him regarding his treatment plan.

01 Greetings02 Explanation of cataract surgery also

complication03 If we do phaco surgery then you will face some

problem3a Left eye will be inactive3b If you use the current glass double

vision

4 You have few option for L/E4 A Secondary implant of IOL in A/C4 B Secondary implant of IOL by scleral fixation4 C You can use Contact lens in L/E

5 ABOUT RIGHT EYE5A R/E will be also Aphakia 5B If Aphakia we need this sort of glass in R/E also5C For the glass the image size will be bigger5D Weight of the glass can make you unhappy6 Any feedback from patient7 Thank’s to the patient

OSPE: 9.Scenario & Question

A 28-year-old obese woman complains of transient

visual loss lasting seconds in the right eye when

rising from a bent position. Examination reveals

normal acuity OU with bilateral disc edema.

QUESTION

1) What may be the cause?

2) What investigation you prefer? And why? Mention

one

3) What history you should take? Mention one

4) What is the long-term visual prognosis?

Answer1) Idiopathic intracranial hypertension, (previously known as

benign intracranial hypertension or pseudotumor cerebri).

2) MRI of the brain. To exclude ICSOL

3) Drug history.

4) In 75% cases visual outcome is good. But in 25% cases

permanent impairment of vision

OSPE: 10. Scenario A boy of 10 year came to you with rapid swelling of the right

eye associated with pain exacerbated by eye movement,

visual impairment and double vision. He has also given history

of flu like symptoms for the last 5 days.

O/E Tender, firm, erythematous and warm eyelids, with

periocular and conjunctival (chemosis) oedema. There is also

reduced VA and impairment of colour vision

Question

1) What is your provisional diagnosis?

2) What might be the cause? Mention 3.

3) Mention 3 D/D.

4) Why impairment of colour vision?

Answer

1) Bacterial orbital cellulitis

2) Streptococcus pneumoniae, Staphylococcus aureus,

Streptococcus pyogenes and Haemophilus

influenzae. (any 3)

3) Fungal orbital infection. Acute dacryocystitis. Acute

orbital haemorrhage.

OSPE: 11. Scenario

It is a diseases of diagnosis of exclusion and should

be investigated fully. Orbit & peri orbital region is

affected

Presentation is with ipsilateral periorbital or

hemicranial pain, and diplopia due to one or more

ocular motor pareses, with pupillary and eyelid

involvement in many cases. Proptosis, if present, is

usually mild.

Question

1) What is your probable diagnosis?

2) What type of disease is this?

3) What is the line of treatment? Mention 2.

4) What is the prognosis?

Answer

1) Tolosa-Hunt syndrome.

2) Granulomatous disease

3) Systemic steroids and other immunosuppressants as

necessary;

4) The clinical course is characterized by remissions

and recurrences.

12. Pain that persists for more than one month after other sings and symptoms disappear

1) What is the probable diagnosis?

2) Which age group is more sufferer?

3) What are the characteristic of pain? Mention 3

4) Why some of the patient suffered from depression?

5) What is the most devastating even life-threatening

condition

6) What are the local treatment? Mention 2

Answer

1) Post-herpetic neuralgia

2) Above 70 year.

3) Pain may be constant or intermittent, worse at night

and aggravated by minor stimuli, touch and heat

4) Neuralgia can impair the QOL, and may lead to

depression.

5) Patient may committed suicide.

6)

Local Cold compresses.

Topical capsaicin 0.075%

lidocaine 5% patches.

13 A patient of 30 year old known case of RP. Now counsel the patient regarding treatment and future plan

1 Glass prescription

2 LVA

3 Field expander

4 Cataract surgery if required

5 Treatment of CMO with acetazolamide

6 Advice ocular examination of other family

member

7 Address other associated systemic problems

8 Genetic counseling

9 Rehabilitation

10 Information regarding any new scientific

development

14 Give a list of what instruments and device you keep ready in a FFA room for schedule and tackle the emergency

1) Emesis basin

2) Oxygen

3) Sphygmomanometer and stethoscope

4) Couch for patient to lie down

5) Ice pack

6) Tourniquet

7) Disposable needles

8) Disposable syringes

9) IV set and scalp vein set

10) Airway device

11) Ambu bag

12) Ing Adrenaline

13) Inj atropine

14) Inj Avil.

15) Inj Betnesol

16) Inj Decadron

17) Inj Deriphylline

18) Inj Dextrose 5%

19) Inj Dextrose 25%

20) Inj Dextrose 50%

OSPE: 15

The device is used to correct emmetropia. What is it?

ANSWER

Is an intracorneal ring which is used to flatten the

cornea and reduces refractive error.

Figure 1Slit-lamp photo of the right eye showing an area of 90% thinning peripherally, extending from the 6:00 to the 1:00 o'clock position. Neovascular changes within the furrow are present with an intact epithelium and a leading edge of lipid deposition anteriorly. The left eye showed similar but much milder changes with a 10% thinning over a three clock hour area.

Examination Vision: CF at 4 ft OD ph 20/200; 20/30 OS ph 20/20 .

Pupils: Normal OU, No APD .

Slit lamp examination: See Figure 1.

Applanation Tonometry: 15 mmHg OU .

Fundus examination: Normal OU .

Corneal Topography: See Figure 2

Question1) What is your diagnosis?2) What is the male female ratio of the disease?3) Which portion of the cornea it starts from?4) What type of astigmatism is there?5) What are the potentially sight threatening

complications in this disorder?6) How would you manage this condition in early and

late stages?

Answer

1) Terrien's marginal corneal degeneration.

2) Male : Female 3:1.

3) Superonasal portion of the cornea,

4) Against the rule astigmatism.

5) Spontaneous perforation or perforation due to minor

trauma occurs in approximately 15% of patients.

06) In early stage, spectacle or RGP or Piggy bag

contact lens. In late stage, Surgery, involving either

crescent-shaped excision of the gutter with suturing

of the margins or peripheral lamellar transplantation,

gives variable results.

OSPE: 17

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.

PARAMETER MARKS1) Identification of the patient

Name 0.5Age 0.25Gender 0.25Address 0.5Mobile No 0.25

2) Operation note

Date & time 0.5Name of surgery 0.5Name of anesthesia 0.5Name of surgeon 0.5

3) Post-operative findings

Visual acuity 1Anterior segment 1Posterior segment 0.5

03 Advice No water to eyeUse dark glassRegular use of medicineAny problem come to doctorFollow up

04) Identification of certificate preparatory

Signature with dateName of the doctor with designationSeal of the department