Specialist & Consultant Ophthalmology oral assessment prep

Knowledge: This is acute post-cataract endophthalmitis until proven otherwise, most often caused by coagulase-negative staphylococci from the patient's own flora. The main differential is toxic anterior segment syndrome, which usually appears within 12 to 48 hours with limbus-to-limbus corneal oedema and less pain. The Endophthalmitis Vitrectomy Study found that immediate vitrectomy benefited patients presenting with light perception only. Those with hand movements or better did as well with vitreous tap and intravitreal antibiotics, although its findings in diabetic patients were less clear. Two cases from one list raise the possibility of a common source, such as contaminated solutions, instruments or a breach in sterile technique.

Management: I would perform a vitreous tap or biopsy today and send samples for Gram stain, culture and, where available, PCR. I would inject intravitreal vancomycin 1 mg in 0.1 mL and ceftazidime 2.25 mg in 0.1 mL, using separate syringes. I would start intensive topical antibiotics and steroids and cycloplegics, and review her within 24 hours, proceeding to vitrectomy if she deteriorates. I would see the second patient urgently and treat in the same way. I would notify the infection control team and suspend the use of the same batch of solutions, viscoelastic and intracameral antibiotics from that list, keeping them for testing. I would review sterilisation records and the theatre process and check on all other patients from the list.

Ethics and communication: I would tell both patients clearly that they have a serious infection related to the surgery, what is being done and what the likely outcomes are, and I would not minimise the event. I would document the disclosure and treatment. If investigation identifies a system failure, patients should be informed of the findings. Protecting future patients takes priority over protecting the reputation of the unit.

Reference: Endophthalmitis Vitrectomy Study Group, Results of the Endophthalmitis Vitrectomy Study (Archives of Ophthalmology, 1995); ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery (2013, updated 2018)

Knowledge: This is acute primary angle closure in the left eye, triggered by pupil dilation from an anticholinergic or sympathomimetic cold remedy in a hypermetropic eye with a crowded anterior segment. The right eye is at high risk because both eyes usually share the same anatomy. Pressure must be lowered quickly to prevent optic nerve and corneal damage, but medical treatment is only a bridge to removing the pupil block. Her asthma rules out topical beta-blockers, and her reduced renal function calls for caution with acetazolamide and mannitol. The EAGLE trial supports clear lens extraction as an effective first-line treatment for primary angle closure with raised pressure.

Management: I would give acetazolamide 500 mg intravenously, using a reduced follow-on dose because of her renal function, together with topical apraclonidine or brimonidine and a topical steroid, avoiding beta-blockers because of asthma. Once the pressure begins to fall, I would start pilocarpine 2% to constrict the pupil. If the pressure remains high after an hour, I would consider intravenous mannitol, monitoring fluid status and renal function. When the cornea clears, I would perform laser peripheral iridotomy in the left eye and prophylactic iridotomy in the right eye, usually within days. If the attack does not resolve or the lens is the main cause, I would plan early lens extraction. I would then assess the optic nerve and fields and arrange long-term follow-up.

Ethics and communication: I would explain to her that the fellow eye is at risk and that preventive laser is strongly advised, and document her consent or refusal. I would advise her to avoid certain cold and travel remedies until treatment is complete and to carry written information. I would also teach the warning symptoms of another attack.

Reference: European Glaucoma Society, Terminology and Guidelines for Glaucoma (5th ed, 2020); American Academy of Ophthalmology, Primary Angle-Closure Disease Preferred Practice Pattern (2020); Azuara-Blanco A et al, Effectiveness of Early Lens Extraction for the Treatment of Primary Angle-Closure Glaucoma (EAGLE, Lancet, 2016)

Knowledge: He has bilateral high-risk proliferative diabetic retinopathy with centre-involving diabetic macular oedema that reduces vision. Anti-VEGF injections treat both macular oedema and neovascularisation, and DRCR Retina Network Protocol S showed that ranibizumab was non-inferior to panretinal photocoagulation for proliferative retinopathy at two years, with less visual field loss. However, anti-VEGF effects are temporary, and patients who miss follow-up can develop severe complications, so panretinal photocoagulation offers more durable protection for unreliable attenders. Protocol T showed that aflibercept gave better results than bevacizumab when baseline vision was 6/15 or worse. Rapid improvement in glycaemic control, including with semaglutide, can temporarily worsen retinopathy.

Management: I would start intravitreal anti-VEGF injections in both eyes, with aflibercept favoured in the right eye given the poorer vision. I would also start panretinal photocoagulation in sessions over the next few weeks because of his attendance history. I would arrange monthly reviews during the loading phase and plan appointments around his work rota. I would write to his physician about his blood pressure, lipids and renal function, and about the risk of early worsening of retinopathy with rapid glucose reduction, so that eye review is closer during this period. I would warn him to report sudden visual loss, which may indicate vitreous haemorrhage or traction detachment, and arrange vitrectomy if non-clearing haemorrhage or tractional detachment threatening the macula develops. I would also advise him on the driving vision standard.

Ethics and communication: I would explain the risk of blindness clearly and agree a plan that he can realistically follow, as care that is not followed cannot work. With his consent, I would write to his employer to support time off for treatment, without sharing details he does not want shared. I would document missed appointments and the efforts made to re-engage him.

Reference: American Academy of Ophthalmology, Diabetic Retinopathy Preferred Practice Pattern; Gross JG et al, Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy (DRCR Network Protocol S, JAMA, 2015); Wells JA et al, Aflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema (DRCR Network Protocol T, New England Journal of Medicine, 2015)

Knowledge: Bilateral optic disc swelling with headache, pulsatile tinnitus and a sixth nerve palsy is papilloedema from raised intracranial pressure until proven otherwise. In a young woman with obesity, idiopathic intracranial hypertension is likely, but cerebral venous sinus thrombosis must be excluded, especially as she takes the combined pill. Other causes include space-occupying lesions, meningitis and drugs such as tetracyclines, retinoids and steroid withdrawal. The diagnosis requires normal brain imaging and cerebrospinal fluid composition with a raised opening pressure. Visual field loss is the main indicator of threat to sight, and visual acuity is preserved until late.

Management: I would arrange urgent MRI brain with MR venography the same day, and then lumbar puncture in the lateral position to measure opening pressure and analyse cerebrospinal fluid. If the diagnosis is confirmed, I would start acetazolamide, increasing the dose as tolerated, and recommend structured weight management, including bariatric referral where appropriate. I would discuss contraception with her and her physicians, since the combined pill raises thrombosis risk and acetazolamide should be avoided in early pregnancy. Because she already has field loss, I would review her within one to two weeks with fields and OCT. If vision deteriorates despite treatment, I would refer urgently to neurosurgery for CSF shunting or to a specialist for optic nerve sheath fenestration or venous sinus stenting, and consider a temporary lumbar drain. I would manage headache without overusing analgesics.

Ethics and communication: I would explain clearly that vision is at risk, as patients often focus on headache. Weight loss advice should be given respectfully and without stigma. I would advise her about driving while visual fields are reduced and document this advice, and seek consent for lumbar puncture with the risks explained.

Reference: Mollan SP et al, Idiopathic Intracranial Hypertension: Consensus Guidelines on Management (Journal of Neurology, Neurosurgery and Psychiatry, 2018); Salmon JF, Kanski's Clinical Ophthalmology: A Systematic Approach (9th ed, 2020)

Knowledge: This is post-refractive surgery corneal ectasia, a progressive thinning and steepening of the cornea. Pre-operative risk factors include abnormal topography, such as asymmetric bow-tie or forme fruste keratoconus, thin corneas, young age, high corrections and a low residual stromal bed or high percentage tissue altered. Corneal cross-linking with riboflavin and UVA light is the standard treatment to stop progression. Corneal thickness should usually be at least 400 micrometres for standard epithelium-off treatment. Visual rehabilitation includes rigid gas-permeable or scleral contact lenses, and keratoplasty is reserved for advanced disease.

Management: I would examine both eyes and repeat tomography, including epithelial mapping if available, to confirm progression and check the left eye. I would offer corneal cross-linking in the right eye soon, since progression is documented and thickness allows standard treatment. I would refer him for contact lens fitting to improve vision. I would advise against any further laser treatment and eye rubbing, and plan follow-up every three to six months. I would treat the left eye if it shows progression. I would give him copies of his records and my findings.

Ethics and communication: I would explain what ectasia is and that some risk factors were present before surgery, but I would not offer an opinion on negligence based on incomplete information or during a clinical consultation. If he pursues a claim, I can provide a factual report of my findings, and expert opinion should come from an independent expert through the proper medicolegal process under Federal Decree-Law No. 4 of 2016. If I had serious concerns about a colleague's practice, I would raise them through professional channels.

Reference: Gomes JAP et al, Global Consensus on Keratoconus and Ectatic Diseases (Cornea, 2015); Randleman JB et al, Risk Assessment for Ectasia after Corneal Refractive Surgery (Ophthalmology, 2008); Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE)

Knowledge: This is bilateral retinoblastoma, which almost always means a germline RB1 mutation, and the father's history suggests an inherited form. The left eye is in an advanced group under the International Intraocular Retinoblastoma Classification, probably group D or E, and the right eye is likely group A or B. Biopsy is contraindicated because it can spread tumour outside the eye. MRI of the brain and orbits is used to assess optic nerve involvement and pineal tumour, and CT should be avoided because radiation increases the risk of second cancers in germline carriers. Treatment aims to save life first, then the eye, then vision.

Management: I would refer immediately to a specialist retinoblastoma centre and arrange MRI of the brain and orbits. For the left eye, primary enucleation with a long optic nerve section is often the safest choice if it is group E, with histology to guide adjuvant treatment. For the right eye, focal therapy such as laser or cryotherapy, possibly with systemic or intra-arterial chemotherapy, aims to save vision. I would arrange genetic testing for RB1 and screening examinations for siblings and any future children. I would plan long-term follow-up for second cancers and recommend avoiding unnecessary radiation. I would coordinate care with paediatric oncology and provide psychosocial support.

Ethics and communication: As she is a minor, her parents give consent, so I would explain the diagnosis, the treatment options and the urgency, and respect their wish to seek treatment abroad while making sure it is not delayed and records are transferred. Consanguinity and the father's history call for sensitive genetic counselling without blame. If the parents refused treatment in a way that endangered her life, I would seek senior and legal advice and consider child protection duties under Federal Law No. 3 of 2016.

Reference: Dimaras H et al, Retinoblastoma (Nature Reviews Disease Primers, 2015); Salmon JF, Kanski's Clinical Ophthalmology: A Systematic Approach (9th ed, 2020)