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Ophthalmology Clinical Vignettes Oral Exam Study Guide PDF
Ophthalmology Clinical Vignettes Oral Exam Study Guide PDF
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
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
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
ISBN 978-0-615-58261-0
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
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
5
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
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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
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
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
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
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.
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,
patient on the wards: CC, HPI, PMH, PSH, Allergies, Meds, FHx, SocHx,
PE, Labs, Assessment, and Plan. Think about writing orders. We all know
so much information, so many variables, and the stakes are so high, that
S.O.P’s early and often. And now we come to yet another challenge, the oral
picture and a clinical vignette on a slide. On the next slide I wrote out a
was easy, but I found my responses were unorganized and difficult to follow.
that a checklist. Using the checklist proved instrumental; I found writing the
9
responses much easier; more important, the responses were more structured,
After several months doing a few cases per day, I had accumulated
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
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
evidently, it worked.
asked to plan and build not one but 13 medical clinics throughout the
outpatient hospital near the Iraq International Airport. Imagine being asked
10
to build, supply, coordinate, and deploy an entire medical facility in the midst
the large slide deck of clinical cases into a book for would-be test-takers to
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
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
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
and that is why oral examinations are such an important part of our
doctors have knowledge, but also the temperament to utilize that knowledge
setting, and inherently replicate some of the tension and anxiety present in
“trick” a candidate. Cases typically presented during oral exams are not
practice. Advanced planning and fastidious preparation are the best methods
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,
prognosis, and patient education. The clinical scenarios cover (1) anterior
segment of the eye, (2) optics, (3) neuro-ophthalmology and orbit, (4)
13
outside the test venue; all candidates agree to these regulations. Therefore,
derive not from our own ABO experience, but from collective experiences in
ample experience and confidence taking written exams. This uneasy feeling
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
preparation plan to be deployed in advance of the test. The text you are
Fortunately, most candidates are now quite familiar with the concept
Organization and adopted by virtually all hospitals in the United States and
Europe. Checklists have been shown not only to decrease the number of
14
groups and individuals on specific objectives. Hospital checklists are
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,
conquer the objectives. With good preparation you will gain confidence,
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.
certification guidelines. This will provide you with information about the
the exam will assess how effectively you acquire clinical data and discuss
You must demonstrate that you possess not only the knowledge but also the
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.
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
(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.
you more easily; it will probably be noted by your examiner. As you recall
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
16
I. Image Description:
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.
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.
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
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
testing alone, it will be useful to sit in front of a mirror. This will allow you
improving verbal presentation skill, and instilling confidence for the oral
examination.
Certainly there is a shelf-life for this kind of preparation; how many of us can
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reproduce the Krebs cycle right now? Our experience suggests that 6 months
instituting the practice sessions in this book 2 to 3 months prior to test day.
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.
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.
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Chapter Two
Optics Cases
John Pemberton DO
˚
Section Reviewer:
23
CASE 22
How can you improve upon the appearance of high minus lenses?
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
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.
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
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.
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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.
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
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.
35
Chapter Five
Pediatric
Ophthalmology Cases
John Pemberton DO
Anthony Daniels MD MSc
˚
Section Reviewer
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.
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.
38
Chapter Six
˚
Section Reviewer
Samir Melki MD
39
CASE 89
48 year-old male complaining of burning and itching of the eyelid.
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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