OPHTHALMOLOGY

CLINICAL VIGNETTES
Oral Exam Study Guide

_________________

John D. Pemberton DO
Assistant Professor of Ophthalmology
University of Arkansas College of Medicine
Oculoplastics & Orbital Reconstructive Surgery
Harvey and Bernice Jones Eye Institute
Little Rock, Arkansas

Anthony B. Daniels MD MSc

Clinical Fellow in Ophthalmology
Vitreoretinal Surgery Service
Harvard Medical School
Assistant in Ophthalmology
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

Aaron Fay MD
Assistant Professor of Ophthalmology
Harvard Medical School
Ophthalmic Plastic and Reconstructive Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

2
 Crimson House Publishing LLC
224 Valmar, Little Rock, Arkansas 72205

OPHTHALMOLOGY CLINICAL VIGNETTES: ORAL EXAM STUDY GUIDE © 2011

No part of this book may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher or
authors. Permission may be sought directly from Crimson House Publishing LLC
website: ophthalmology.oralboardprep.com

Notice
Ophthalmology is a constantly changing profession. Standard
precautions must be followed as new research and clinical findings
widen the knowledge base, changes in treatment may be necessary.
Readers should check current information for medications and
management of cases and not use this book as a therapeutic reference
guide. It is the responsibility of the licensed practioner to determine the
best treatment of their patients. Neither the publisher nor the authors
assume any liability for any injury and/or damage to individuals or
property arising from this publication.

Disclaimer
This book has been written based on public information
gathered from the American Board of Ophthalmology (ABO) website,
printed policies, and our own personal and clinical experience. No
ABO material has been replicated, recalled, or taken from the actual
examination. Clinical cases and material in this book that seems to be
similar is coincidental as it is impossible to know what specific material
will be covered on any given exam day. It is against ABO rules to
divulge specific information regarding prior or future examination
content.
The Publisher

Library of Congress Control Number: 2011963533

ISBN 978-0-615-58261-0

Printed in USA by 48HrBooks (www.48HrBooks.com)

3
 Section Reviewers
We would like to thank the following professors and instructors who
generously provided the input and advice on which the refinements and
enhancements to this book are based.

Dean Cestari MD
Assistant Professor of Ophthalmology
Harvard Medical School
Neuro-ophthalmology and Adult Strabismus
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

Samir Melki MD, PhD

Assistant Professor of Ophthalmology
Harvard Medical School
Cornea and Refractive Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

Ankoor S. Shah, MD, PhD

Instructor, Department of Ophthalmology
Harvard Medical School
Pediatric Ophthalmology
Children’s Hospital Boston
Boston, Massachusetts

Demetrios Vavvas MD, PhD

Assistant Professor of Ophthalmology
Harvard Medical School
Vitreoretinal Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

Michael N. Wiggins MD
Associate Professor of Ophthalmology
University of Arkansas College of Medicine
Comprehensive Ophthalmology
Associate Residency Director & Director of
Ophthalmic Medical Technology
Harvey and Bernice Jones Eye Institute
Little Rock, Arkansas

4
 Table of Contents
Preface 11
Introduction 15
Chapter 1: Anterior Segment Cases 23
Case 1: Vernal Keratoconjunctivitis……….. 24
Case 2: Whorl Keratopathy………………… 26
Case 3: Recurrent Corneal Erosion………… 28
Case 4: Keratoconus……………………….. 30
Case 5: Peripheral Ulcerative Keratitis…….. 32
Case 6: Anterior Uveitis……………………. 34
Case 7: Pigment Dispersion………………… 36
Case 8: Salzmann Nodules………………….. 38
Case 9: Filamentary Keratitis……………….. 40
Case 10: HSV Keratitis………………………. 42
Case 11: Angle Closure Glaucoma…………… 44
Case 12: Viral Conjunctivitis………………… 46
Case 13: Blebitis……………………………… 48
Case 14: Fuch’s, Corneal edema……………… 50
Case 15: Subluxed lens……………………….. 52
Case 16: Pseudoexfoliation…………………… 54
Case 17: Hyphema……………………………. 56
Case 18: Corneal Ulcer……………………….. 58
Case 19: Scleritis……………………………… 60
Case 20: Chemical Burn…………………….. 62

Chapter 2: Optics Cases 65

Case 21: Causes of astigmatism……………… 66
Case 22: Improve high minus glasses………... 68
Case 23: Keep glasses on a child…………….. 70
Case 24: Accommodative amplitude………… 72
Case 25: Transpose a glasses prescription…… 74
Case 26: Correction of astigmatism………….. 76
Case 27: Adjust intraocular lens power……….. 78
Case 28: Duochrome test…………………….. 80
Case 29: What is the Geneva lens clock……… 82
Case 30: What is a lensometer………………... 84
Case 31: Patient unhappy with glasses……….. 86
Case 32: Assess vision in dense cataracts……. 88
Case 33: Causes of acquired hyperopia………. 90

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 Case 34: Having trouble seeing at night……… 92
Case 35: With the rule astigmatism………….. 94
Case 36: What is a distometer………………... 96
Case 37: Seeing double in current glasses…… 98
Case 38: What can bother aphakic patients?….. 100
Case 39: Causes of acquired myopia………… 102
Case 40: Approach to low vision patients…… 104

Chapter 3: Posterior Segment Cases 107

Case 41: Macular hole……………………….. 108
Case 42: Bull’s eye maculopathy……………. 112
Case 43: Sickle cell retinopathy……………... 114
Case 44: CRVO……………………………… 116
Case 45: CRAO……………………………… 118
Case 46: BRVO……………………………… 120
Case 47: Toxoplasmosis……………………... 122
Case 48: Purtscher’s retinopathy…………….. 124
Case 49: Stargardt’s Disease………………… 126
Case 50: CMV……………………………….. 128
Case 51: Choroidal Melanoma………………. 130
Case 52: Retinal Tear, Horseshoe………….... 132
Case 53: AMD……………………………….. 134
Case 54: Crystalline Retinopathy……………. 136
Case 55: CME……………………………….. 138
Case 56: Diabetic Retinopathy………………. 140
Case 57: Post Cataract Endophthalmitis……... 142

Chapter 4: Neuro-ophthalmology and

Orbit Cases 145
Case 58: Optic Nerve Hypoplasia……………. 146
Case 59: Drusen of optic nerve………………. 150
Case 60: Optic nerve Glioma………………… 154
Case 61: Carotid Cavernous Fistula…………... 158
Case 62: 4th nerve palsy……………………… 162
Case 63: 6th nerve palsy……………………… 164
Case 64: 7th nerve palsy……………………… 166
Case 65: Horner’s Syndrome…………………. 170
Case 66: Bilateral Disc edema………………... 172
Case 67: Unilateral Disc Edema……………… 174
Case 68: Optic Neuritis……………………….. 176

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 Case 69: 3rd Nerve Palsy……………………... 178
Case 70: Orbital Cellulitis…………………….. 180
Case 71: Thyroid Orbitopathy………………… 184
Case 72: Rhabdomyosarcoma………………… 188
Case 73: Optic Nerve Meningioma…………... 192

Chapter 5: Pediatric Ophthalmology Cases 197

Case 74: Congenital Glaucoma……………..... 198
Case 75: JRA and Bank Keratopathy……….... 200
Case 76: Neonatal Conjunctivitis…………….. 202
Case 77: Retinopathy of prematurity…………. 204
Case 78: Leukocoria………………………….. 206
Case 79: Large angle esotropia………………. 208
Case 80: Large angle exodeviation…………... 210
Case 81: Bilateral media opacities………….... 212
Case 82: Hemangioma of the upper lid………. 214
Case 83: Young boy with dislocated lens……. 216
Case 84: Epiphora neonate………………….... 218
Case 85: Pseudostrabismus…………………… 220
Case 86: Child with anisocoria……………….. 222
Case 87: Congenital ptosis……………………. 224
Case 88: Sturge-Weber (Nevus Flammeus)…... 226

Chapter 6: External Disease Cases 229

Case 89: Blepharitis…………………………... 230
Case 90: Chalazion………………………….... 232
Case 91: Molluscum………………………….. 234
Case 92: Squamous carcinoma of conjunctiva.. 236
Case 93: Pterygium…………………………… 238
Case 94: Pigmented Conjunctival Lesion…….. 240
Case 95: Herpes Zoster……………………….. 242
Case 96: Lymphoma………………………….. 244
Case 97: Dacryocystitis………………………. 246
Case 98: Symblepharon………………………. 248
Case 99: BCCA……………………………….. 250
Case 100: Chronic Unilateral Blepharitis…….. 252

7
 Preface
When I set out to prepare for the oral examination, writing a book

was not what I had in mind. Actually, I set out looking for a manual, like I

had on just about every assignment I’d been given over the past two decades.

In the rare cases where there was no S.O.P. (standard operating procedure),

I’d had to write them. So naturally, when I could not locate a suitable study

guide, I set about creating one. Little did I know, with encouragement from

some close colleagues, it would culminate in this volume; think of it as an

oral test prep S.O.P.

In a certain sense, you could say I began writing this book 20 years

ago when I first enlisted in the United States Air Force (and later moved to

the United Stated Army with its greater opportunities in medicine). There I

first learned the concepts of preparation and planning. I learned the value of

regimentation and repetition, and saw first-hand how enormous challenges

could be conquered with commitment, cooperation, planning, and good old

fashioned hard work. But I also learned that hard work alone is sometimes

not enough. In the Army we needed each other, and we relied on those who

came before us to leave roadmaps and other indicators of how best to

succeed in the most grueling circumstances. I may not have liked everything
8
at the time, but when we arrived in Baghdad, the S.O.P’s literally saved my

life.

A medic in Iraq obviously faces different challenges from a medical

resident back home, but there are some similarities, and my military training

did help during medical school and on the wards as a resident. Here again,

it’s all about preparation and standardization. Think about presenting a

patient on the wards: CC, HPI, PMH, PSH, Allergies, Meds, FHx, SocHx,

PE, Labs, Assessment, and Plan. Think about writing orders. We all know

the acronym ADCVANDIMSL. These are S.O.P’s for physicians. There is

so much information, so many variables, and the stakes are so high, that

nothing can be left to chance. The successful residents internalize these

S.O.P’s early and often. And now we come to yet another challenge, the oral

examination. Time for a new S.O.P.

Knowing that I do well with structure and organization, I started to

prepare for the examination by making PowerPoint slides. I put a clinical

picture and a clinical vignette on a slide. On the next slide I wrote out a

paragraph of what I would say to an examiner. Making the clinical scenarios

was easy, but I found my responses were unorganized and difficult to follow.

So I went back to what I used to do on the wards as an intern. Back then I

used a template to systematically organize my thoughts. Nowadays they call

that a checklist. Using the checklist proved instrumental; I found writing the

9
responses much easier; more important, the responses were more structured,

succinct, and comprehensible.

After several months doing a few cases per day, I had accumulated

quite a slide deck of common ophthalmic problems, which I used to prepare

for the exam. At first I was studying alone but knew I needed to create a

situation that mirrored the actual exam to prepare properly. In the Army we

used to do combat simulations to prepare for real battle. Our motto was, “fail

to prepare, prepare to fail.” In 2004, our preparation and training was tested

and proved successful during our year-long deployment outside the green

zone in Baghdad, Iraq. I think we would agree that real combat is no time to

discover you are ill-prepared. As we say and do in the Army, “prepare like

you intend to fight.” I realized I needed to improve my combat simulation or

what the Army calls an FTX (field training exercise).

In the months leading to the exam I recruited a study partner and we

set up a mock testing environment in a room using a desk and two opposing

chairs, and alternated roles of examiner and examinee. The study process

turned out to be a blast and I think we benefited by employing this strategy;

evidently, it worked.

Not everything in the Army was battle. I had no idea I would be

asked to plan and build not one but 13 medical clinics throughout the

southwest sector of Baghdad. In addition I was task to build a full service

outpatient hospital near the Iraq International Airport. Imagine being asked

10
to build, supply, coordinate, and deploy an entire medical facility in the midst

of hostile terrain. Fortunately, I could call on my experiences in preparation,

planning, and tenacious follow-through. We were able to erect a successful

medical center in 6 months, further evidence that careful preparation and

fastidious commitment pay off.

After successfully navigating the oral exam, I felt compelled to turn

the large slide deck of clinical cases into a book for would-be test-takers to

use in preparing for the nerve-wracking oral exam. However, compulsion

was not enough; I needed prompting, which I obtained from my friends and

colleagues Drs. Aaron Fay and Anthony Daniels. It is because of them that

those slides finally have been converted into a book, that sweat into an S.O.P.

It is my sincere hope that this book proves useful, provides confidence, and

offers an enjoyable method in preparing for the oral examination.

11
 Introduction
There is no doubt that test-taking is a skill unto itself, and if you are

reading this book, it is a skill you have pretty well mastered. While standard

written tests are presently under great scrutiny (several universities have

recently eliminated SATs from undergraduate admissions), they remain a

major part of academic life. In the present era of medical training, we are all

more accustomed to written tests than we are to oral examinations, but this

was not always the case. For most of history, apprenticeships were the sole

source of medical training, and the only form of examination was the spoken

word. We now find ourselves in the predicament of having to prepare for

old-fashioned oral examination at the 11th hour of training.

Clinical medicine is based, at its root, on direct personal interaction,

and that is why oral examinations are such an important part of our

evaluation process. Patient care is simply too complex to assess a candidate

based on factual regurgitation alone. Patients need to be confident that their

doctors have knowledge, but also the temperament to utilize that knowledge

under stressful conditions. Oral examinations attempt to approximate that

setting, and inherently replicate some of the tension and anxiety present in

patient-physician encounters. They are designed to assess clinical

12
knowledge and clinical judgment fairly and objectively; they do not intend to

“trick” a candidate. Cases typically presented during oral exams are not

“fascinomas,” but cases a physician should expect to encounter in general

practice. Advanced planning and fastidious preparation are the best methods

to overcome this important obstacle.

The American Board of Ophthalmology (ABO) oral examination is

given twice per year in selected cities throughout the United States. The

exam lasts one half day and is divided equally into six timed testing sessions,

each with different examiners. This allows multiple examiners to assess a

candidate’s ophthalmic knowledge and patient management disposition.

Examiners are selected by their peers from a pool of practicing

ophthalmologists to proctor the examination process. The examiners present

clinical scenarios including photographs and written vignettes. They expect

the examinee to discuss the clinical history including pertinent negatives,

accurate and succinct description of findings, focused differential diagnoses,

key diagnostics tests, case management, pertinent treatment, follow-up,

prognosis, and patient education. The clinical scenarios cover (1) anterior

segment of the eye, (2) optics, (3) neuro-ophthalmology and orbit, (4)

posterior segment of the eye, (5) pediatric ophthalmology and strabismus,

and (6) external eye and adnexa.

Like other standardized testing organizations, the American Board of

Ophthalmology (ABO) prohibits transmission of test content and format

13
outside the test venue; all candidates agree to these regulations. Therefore,

the representations and recommendations provided throughout this manual

derive not from our own ABO experience, but from collective experiences in

oral examination within and beyond medicine. The depictions and

suggestions herein can be generalized to all oral exams.

In our experience, we have found that most physicians and

physicians-in-training find oral exams daunting and uncomfortable, despite

ample experience and confidence taking written exams. This uneasy feeling

can be managed universally with committed preparation. The problem is not

the desire to prepare, but how to prepare. Oral board preparation courses

typically take place the week prior to the examination date. These provide

useful “brush-ups”, but do not allow sufficient time. Many candidates rely

on advice from more senior residents or colleagues, who typically

recommend reviewing atlases and picture books. We find this approach

insufficiently organized. Therefore, we recommend a regimented

preparation plan to be deployed in advance of the test. The text you are

holding represents just such a system.

Fortunately, most candidates are now quite familiar with the concept

of a checklist, popularized in medicine in the recent past by the World Health

Organization and adopted by virtually all hospitals in the United States and

Europe. Checklists have been shown not only to decrease the number of

errors of omission, but also to eliminate errors of commission by focusing

14
groups and individuals on specific objectives. Hospital checklists are

frequently posted on a wall to be followed by a group. Alternatively, mental

checklists can help keep an individual focused and precise. When driving a

car, for example, one checks his/her keys, driver’s license, seat belt,

navigation system, cell phone, and of course coffee.

While an oral examination is difficult, this manual will provide you

with a veritable checklist, a systematic approach to navigate the process and

conquer the objectives. With good preparation you will gain confidence,

decrease anxiety, and improve your performance on testing day. Arriving

unprepared to take the test will likely yield poor results; it is not an approach

we advocate, as you may very well return later only to take the test again.

Step 1 is to go to the ABO website (www.abop.org) and read the board

certification guidelines. This will provide you with information about the

history, purpose, format, and expectations for the examination. In general,

the exam will assess how effectively you acquire clinical data and discuss

appropriate diagnoses, assessments, plans, patient education and follow-up.

You must demonstrate that you possess not only the knowledge but also the

ability to apply this knowledge appropriately, safely and effectively. The

ABO defines the following skills that a candidate should demonstrate in

order to pass the examination, (1) data acquisition, (2) diagnosis, and (3)

treatment.

15
 This manual is structured to simplify the studying process. You will

see that on one page you have a clinical vignette and a clinical photograph.

On the opposite page is a reasonable response to the scenario. The responses

in this book should be used as guidelines in helping you prepare for the

exam, and not considered sole authoritative answers. As you will see, the

responses are outlined in a structured format (1) image description, (2)

differential diagnosis, (3) history/physical exam/evaluation, (4) assessment,

(5) plan, and (6) patient education. You will find that a systematic approach

like this one creates a checklist that is useful in organizing your thoughts and

will help you present your case in a cohesive and comprehensible manner.

Additionally, presenting in an organized manner helps your listener follow

you more easily; it will probably be noted by your examiner. As you recall

from presenting cases on the wards, standardized formats are commonplace

in medicine:

Chief Complaint
History of Present Illness
Past Medical History
Past Surgical History
Medications
Allergies
Social History
Family History
Review of Systems
Physical Exam
Laboratory Results
Assessment
Plan

What follows is a more detailed description of the structured format

used in this textbook:

16
 I. Image Description:

When presented with a picture you should start by describing the

findings in broad terms and refrain from buzz words that narrow
your differential even if you are certain about the diagnosis. For
example, if you are describing a mottled retina with drusen-like
speckles, do not use the term “peau d’orange,” as that would
indicate a specific diagnosis. The examiner may want to know
not only your final answer, but also how you got there. Buzz
words can potentially paint you into a corner.

II. Differential Diagnosis:

Identify at least 3 to 4 possible diagnoses for each case.

III. History/Physical Exam/Evaluation:

Here you want to narrow the differential by discussing history,

findings and tests that rule out some of the diagnoses you
mentioned. It is important to eliminate potentially critical
diagnoses from your differential list. You then focus on a
working diagnosis and discuss how you would proceed.

IV. Assessment:

Here you expand upon your working diagnosis and reiterate why
the diagnosis is the correct diagnosis, and perhaps why other
important diagnoses under consideration are not the correct
diagnosis. For example, “In this case we have a young boy with
giant papillary reaction on the upper lid and history of atopy
which is most consistent with the diagnosis of vernal
keratoconjunctivitis…..”

V. Plan:

Now you discuss the treatment and management of the case. You
want to offer conservative treatment alternatives, and only later
escalate to aggressive intervention, unless specifically indicated.

VI. Patient Education:

Finish the case with how you would educate the patient and
family. You’ll want to hit on the nature of the condition,
prognosis, and follow up.
17
 This manual can be used in several ways. You can use it for self-

assessment, or with a study partner. We have found the latter to be not only

more entertaining, but also to simulate the testing experience more closely.

Furthermore, when testing oneself it is difficult to avoid “cheating” by

looking ahead at the answers. That caveat allows you to fool yourself into

thinking “oh yeah, I would have said that.” Having someone else monitor

you keeps even the most studious pupil honest.

The truly committed candidate may want to set up a mock testing

area in an apartment with a table or desk and two chairs on opposite sides.

Take turns with your study partner in the roles of examiner and examinee.

The mock examiner should use the responses in the book as a guide for the

case. After completing a case or a group of cases the person who acted as the

examiner should critique the session honestly. Inevitably, this will lead to

good discussions, important self-assessment, and a lot of laughs. When

testing alone, it will be useful to sit in front of a mirror. This will allow you

to observe your nervous habits and curtail unnecessary distractions. In either

situation, the book is quite helpful in augmenting the preparation process,

improving verbal presentation skill, and instilling confidence for the oral

examination.

Finally, a word about timing. In show business they say timing is

everything; in oral board preparation it is not everything but it is something.

Certainly there is a shelf-life for this kind of preparation; how many of us can

18
reproduce the Krebs cycle right now? Our experience suggests that 6 months

is too long a period of intense preparation, although general reading should

be ongoing for all the months leading up to the exam. We recommend

instituting the practice sessions in this book 2 to 3 months prior to test day.

You will be fresh, well prepared, and confident. Congratulations!

References:

American Board of Ophthalmology Board Certification (2011). Retrieved Nov. 2011 from
http://www.abop.org/Cert%20Brochure.pdf

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 Chapter One

Anterior Segment
Cases
John D. Pemberton DO
Anthony Daniels MD MSc

˚
Section Reviewer

Samir Melki MD

20
 CASE 11

49 year old Asian female with blurred vision, eye pain, halos in vision,
nausea, and vomiting.

Photo courtesy of Benjamin Wu MD

21
 CASE 11
I Image Description:
o Corneal edema, mid-dilated pupil
II Differential Diagnosis:
o Acute angle closure glaucoma, pupillary block, plateau iris
o PAS, neovascular glaucoma
o Phacomorphic glaucoma, zonular weakening (trauma, PXF, Marfan’s)
o Posterior segment mass
o Choroidal effusion: Topamax, buckle, excess laser
o Aqueous misdirection
III History/Physical Exam/Evaluation:
o Would ask about family history of acute angle closure, hyperopia. Would
ask about precipitating event (i.e. dim light, flu therapies), mydriatics, eye
surgery, retinal laser, Topamax, sulfonamides, and trauma. Examine for
keratitic precipitates (KP), posterior synechiae, iris atrophy, iris
neovascularization, mid-dilated pupil, swollen enlarged lens, anterior
chamber reaction, glaucomaflecken. Gonio angle to look for peripheral
anterior synechiae (PAS). May need to perform a dynamic gonio to open
angle to identify PAS. Evaluate opposite eye for occludable angle. Look
for findings of iris bombe and pupillary block. Perform a fundus exam
looking for ischemic factors (CRVO, DM, and CRAO). Would look at
optic nerve for spontaneous pulsation and cupping. Look for ciliary body
tumors and choroidal effusion. If no view of posterior pole; obtain a B
scan.
IV Assessment:
o The Asian patient has a mid-dilated pupil, corneal edema, nausea and
vomiting, which suggest a diagnosis of acute angle closure.
V Plan:
o Lower IOP with Timolol, CAI (unless sulfonamide allergy), brimonidine.
Recheck eye pressure and vision in 1 hour. If not better, admit, start oral
CAI’s; ensure renal function good and no intracranial bleed or hypotension.
Once pressure under control and cornea clear perform laser peripheral
iridotomy (LPI). If other eye has an occludable angle would consider LPI
of this eye in the near future. If aqueous misdirection; treat with medical
therapy and mydriatics. If no change, then open posterior capsule in
pseudophakic patients. If patient phakic and has a patent PI can laser
vitreous face through PI, otherwise may need vitrectomy to reverse aqueous
misdirection. If angle closure due to due to iris neovascularization then
lower eye pressure and perform laser PRP when possible. If a choroidal
effusion, then lower eye pressure, start steroids, and mydriatics. If
Phacomorphic then lower eye pressure and cataract surgery when possible.
VI Patient Education:
o Guarded and depends on length eye pressure was elevated, good potential if
diagnosed and treated early.

22
 Chapter Two

Optics Cases
John Pemberton DO

˚
Section Reviewer:

Michael N. Wiggins, MD, FACS, OCS

23
 CASE 22
How can you improve upon the appearance of high minus lenses?

Photo courtesy of John Pemberton DO

24
 CASE 22
The first thing to ensure is whether the refraction is correct. Patients

with high minus lenses complain of barrel distortion, minification and glasses

appearance. You help minimize these issue by making the lenses smaller,

use thicker frame designs, bevel the edges of the lenses, use higher index

material to decrease weight, flatter base curve for the front of the glasses and

consider discussing contact lenses or refractive surgery, when appropriate.

25
 Chapter Three

Posterior Segment
Cases
Anthony Daniels MD MSc
John Pemberton DO

˚
Section Reviewer

Demetrios Vavvas MD

26
 CASE 41
68-year-old female with complaints of decreased vision.

Photo courtesy of Massachusetts Eye and Ear Infirmary

27
 CASE 41
I Image Description:
o Fundus photo with central red spot with surrounding cuff of
fluid, small yellow precipitates within spot
II Differential Diagnosis
o Macular hole
o Macular pucker
o CME intraretinal cyst
III History/Physical Exam/Evaluation:
o Previous trauma, previous eye surgery. Complete eye exam,
especially of the macula. Perform a Watzke-Allen test by
projecting a slit beam and seeing if line broken or distorted.
Distorted consistent with pucker and broken with hole.
Intravenous fluorescein angiography (IVFA) demonstrates early
hyperfluorescence with no leakage for hole. OCT is the preferred
mode of further testing.

28
 CASE 41

Photo courtesy of Massachusetts Eye and Ear Infirmary

29
 CASE 41
I Image Description:
o OCT showing full thickness macular hole with cuff.
IV Assessment:
o Full thickness macular hole stage 4
V Plan:
o Macular holes are grouped into stages. Stage I is an impending
hole, stage II-IV is full thickness hole. Stage II is <400 microns,
no posterior vitreous detachment (PVD), Stage III is >400
microns and no PVD or operculum, Stage IV is hole with cuff
and complete PVD. Observe stage I as 50% will resolve
spontaneously. Vitrectomy with or without internal limiting
membrane (ILM) peel for stage II-IV. If operated within first 6
months can regain half the visual loss. Others operate up to a
year. Small portion of patients may benefit even if long standing
history of hole. New drugs in the horizon like ocriplasmin may
be used for stage II hole with 50-60% success rate.
VI Patient Education:
o Low risk for RD but must explain signs and symptoms to patient.

30
 Chapter Four

Neuro-ophthalmology
and Orbit Cases
John D. Pemberton DO
Anthony Daniels MD MSc

˚
Section Reviewer

Dean Cestari MD

31
 CASE 58
Young child with esotropia and an afferent pupillary defect sent for
evaluation.

Photo courtesy of Lawrence Tychsen MD

32
 CASE 58
I Image Description:
o Disc photo of a young child demonstrating an anomalous nerve
with a double ring sign consistent with optic nerve hypoplasia.
II Differential Diagnosis:
o Optic nerve hypoplasia
o Can be associated with CNS defects or can be isolated
o If CNS abnormalities then known as Septo-optic dysplasia or
DeMorsier Syndrome
o Optic atrophy (genetic or tumor)
o Coloboma
o Optic nerve pit
III History/Physical Exam/Evaluation:
o Patient has double ring sign and optic nerve hypoplasia.
Although this can be an isolated finding, this patient warrants
neuroimaging of the brain and orbit looking for absence of the
septum pellucidum and/or corpus callosum.
o Given the high association of endocrine abnormalities, especially
growth hormone deficiency, must ask about history of failure to
thrive, milestones, and growth patterns.

33
 CASE 58

Photo courtesy of Lawrence Tychsen MD

34
 CASE 58
I Image Description:
o MRI shows absence of the septum pellucidum and attenuation of
the corpus callosum (need arrows on MRI).
IV Assessment:
o Septo-optic dysplasia/De Morsier Syndrome
V Plan:
o Patient will need endocrine evaluation and pediatric follow up as
these patients can have significant pituitary hormone deficiencies
such as deficient growth hormone and adrenocorticotropine
hormone (ACTH). Patient with endocrine deficiencies will need
hormone supplementation. .
VI Patient Education:
o The range of vision from can be from 20/20 to no light
perception (NLP).
o If compliant with follow-up and medication for hormone
deficiencies, patients have a good prognosis for productive lives.

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 Chapter Five

Pediatric
Ophthalmology Cases
John Pemberton DO
Anthony Daniels MD MSc

˚
Section Reviewer

Ankoor S. Shah MD PhD

36
 CASE 75
A 6 year-old girl presents with a “white spot” on her eye. Her parents report
an intermittent history of blurred vision but no eye pain in the past.

Photo courtesy of Danielle Ledoux MD

37
 CASE 75
I Image Description:
o Eye with early band keratopathy nasally and temporally
II Differential Diagnosis:
o Juvenile idiopathic arthritis (JIA)
o Chronic retinal detachment
o Intraocular silicon oil
o Trauma with subsequent phthisical eye
o Metabolic d/o (hyperparathyroidism, hypercalcemia, or vit D toxicity)
o Inflammatory conditions (sarcoidosis, gout) and Malignancy
III History/Physical Exam/Evaluation:
o Young girl with band keratopathy, I would seek a history of uveitis,
ocular trauma, ocular surgery, or retinal detachment repair. A careful
ROS to elucidate history of joint pain or swelling associated with
arthritis, systemic metabolic disorders, or renal failure that can lead to
hypercalcemic states. Would document vision and then focus on
anterior segment. Would perform a slit-lamp exam to confirm the
diagnosis of band keratopathy looking for deposits in the interpalpebral
zone starting in the limbal regions of 3 and 9 o’clock. Would look to
see that its location is indeed within Bowman’s layer. Would examine
the corneal endothelial surface for keratic precipitates, and look at the
anterior chamber for findings indicative of active inflammation. Would
also study the iris and lens looking for posterior synechiae, iris bombe,
and cataract. A measurement of eye pressure would be critical to
ensure that it is not elevated, and a dilated exam to rule-out posterior
pathology (optic nerve cupping and post. inflammation). Would
evaluate hands, wrists, knees, and ankles for arthritic signs and palpate
thyroid for enlargement. Would obtain rheumatoid factor (RF), anti-
nuclear antibody (ANA), calcium, phosphorous, angiotensin converting
enzyme, and lysozyme labs to rule-in JIA and rule-out sarcoid and
metabolic d/o.
IV Assessment:
o Band keratopathy associated with chronic inflammation likely from JIA
V Plan:
o Would have evaluation by rheumatology especially if no evidence of
metabolic d/o or renal disease. If arthritis and uveitis are active would
start treatment (i.e. steroids, methotrexate). If band keratopathy affects
visual axis or causes chronic irritation can use EDTA chelation
(disodium ethylenediaminetetraacetic acid)
VI Patient Education:
o Would discuss natural progression of chronic inflammation and the
development of cataracts, glaucoma, cystoids macular edema, and band
keratopathy with the parents. Would inform them that follow–up every
3 months is needed to monitor uveitis; as pauci-articular, RF- and
ANA+ JIA can be silent, recurrent, and refractory to treatment.
Moreover, inflammation can also occur in other forms of JIA.
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 Chapter Six

External Disease Cases

John Pemberton DO

˚
Section Reviewer

Samir Melki MD

39
 CASE 89
48 year-old male complaining of burning and itching of the eyelid.

Photo courtesy of Massachusetts Eye and Ear Infirmary

40
 CASE 89
I Image Description:
o Lids with telangiectasia, scurf, and crusting without lash loss
II Differential Diagnosis:
o Blepharitis
o Ocular Roseacea with blepharitis
o Herpes Simplex Keratitis
o Sebaceous Cell carcinoma
III History/Physical Exam/Evaluation:
o External examination looking at face for rhinophyma, facial
telangiectasia, look at slit lamp for telangiectasia, scurf, lash
loss, cornea for pannus, dendrites
IV Assessment:
o Blepharitis
V Plan:
o Chronic management usually required but as symptoms improve
the medications can be reduced. Treatment is with warm
compresses, lid washes, avoidance of exacerbating foods/drinks
like alcohol, spicy food if Rosacea. Doxycycline treatment for
matrix metalloproteinase (MMP) inhibition and metrogel for
control of facial rosacea. I would avoid ocular steroids in
patients with ocular rosacea as they can develop corneal
thinning, which can lead to perforation. Lastly these patients can
develop chalazia, which can be treated in a similar fashion as the
blepharitis; however some will need to be managed surgically
with incision and drainage.
VI Patient Education:
o I would explain to the patient that treatment is typically long
term, however would encourage them that as symptoms improve
the medication, warm compresses, and lid scrub regimen can be
reduced. For those taking oral tetracycline I would discuss
minimizing sun exposure. I would not prescribe tetracycline to
children or to women who are pregnant or nursing.

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