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  • PassPACES Ophthalmology For Station 5 of The PACESExamination

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    Ibrahim Abbass
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    This document provides guidance for ophthalmology scenarios that may arise in Station 5 of the PACES examination. It outlines the key information to obtain from patients presenting with loss of central vision, peripheral visual field loss, or double vision. For any presentation, it is important to establish the onset, progression, laterality and impact of symptoms. Specific causes are discussed for loss of vision such as macular disease or optic nerve involvement. For double vision, it reviews potential cranial nerve palsies and other conditions like myasthenia. Pupil examination is also highlighted to localize any neurological deficit.

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    PassPACES Ophthalmology for Station 5 of the PACESExamination

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    This document provides guidance for ophthalmology scenarios that may arise in Station 5 of the PACES examination. It outlines the key information to obtain from patients presenting with loss of central vision, peripheral visual field loss, or double vision. For any presentation, it is important to establish the onset, progression, laterality and impact of symptoms. Specific causes are discussed for loss of vision such as macular disease or optic nerve involvement. For double vision, it reviews potential cranial nerve palsies and other conditions like myasthenia. Pupil examination is also highlighted to localize any neurological deficit.

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    31 views2 pages

    PassPACES Ophthalmology For Station 5 of The PACESExamination

    Uploaded by

    Ibrahim Abbass
    This document provides guidance for ophthalmology scenarios that may arise in Station 5 of the PACES examination. It outlines the key information to obtain from patients presenting with loss of central vision, peripheral visual field loss, or double vision. For any presentation, it is important to establish the onset, progression, laterality and impact of symptoms. Specific causes are discussed for loss of vision such as macular disease or optic nerve involvement. For double vision, it reviews potential cranial nerve palsies and other conditions like myasthenia. Pupil examination is also highlighted to localize any neurological deficit.

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    PassPACES MRCP Clinical Courses

    Ophthalmology for Station 5 of the PACES Examination


    For the Short Clinical Consultations in Station 5, candidates are given 8 minutes with each
    patient to take a focussed history, carry out a relevant examination, and respond to the
    patient’s concerns.

    Ophthalmology scenarios will typically involve:


    1) loss of central vision; 2) peripheral visual field loss or 3) double vision.

    In all scenarios it is important to ascertain:


    • Date of onset of symptoms (including history of trauma if appropriate)
    • Rate of progression (e.g. sudden onset strongly suggests a vascular aetiology whereas
    gradual onset might indicate a compressive lesion)
    • Whether the complaint is monocular or binocular.
    • Whether there is any associated pain / systemic symptoms
    • Whether symptoms are constant or intermittent / variable during the day
    • What effect the visual loss / diplopia is having on the patients activities of daily living

    Loss of vision:

    Loss of central vision may be due to:


    • Macular disease (e.g. diabetic maculopathy, age-related macular degeneration)
    • Retinal vein occlusion or hypertensive retinopathy causing macular oedema
    • Optic nerve disease (optic neuritis)
    • Cataract

    Loss of peripheral vision may be due to:


    • Retinitis pigmentosa
    • Glaucoma
    • Retinal artery occlusion
    • Ischaemic optic neuropathy
    • Cerebrovascular disease
    • Chiasmal lesion

    Acute loss of vision:


    Sudden monocular visual loss suggests an ischaemic lesion in the eye (retinal vascular
    occlusion) or optic nerve (anterior ischaemic optic neuropathy), whereas sudden binocular
    visual loss indicates a cortical vascular event.
    • It is essential to exclude giant cell arteritis (headache, jaw claudication, weight loss etc) in
    patients with sudden monocular visual loss.
    • Optic neuritis typically causes vision to deteriorate over several days and is associated
    with pain

    Gradual loss of vision:


    Unilateral: may reflect a local (e.g. compressive) cause rather than a systemic one.
    Bilateral: could be inherited, degenerative (age-related), toxic, nutritional.

    www.passpaces.co.uk Tel: 07 971 971 000


    PassPACES MRCP Clinical Courses

    Double vision

    Monocular diplopia is usually caused by cataract.

    Binocular diplopia may be caused by:


    • Third nerve palsy
    • Fourth nerve palsy
    • Sixth nerve palsy
    • Intra-nuclear ophthalmoplegia
    • Myasthenia
    • Dysthyroid eye disease
    • Ocular myopathies: e.g. Mitochondrial cytopathies

    Establish whether the patient experiences horizontal or vertical diplopia and in which
    direction the double vision is most noticeable.
    Horizontal diplopia, which is worse in the distance, suggests a sixth nerve palsy.
    Vertical diplopia that is at its worst in downgaze is likely to be due to a fourth nerve palsy.

    Intermittent / variable diplopia suggests myasthenia.


    This may be associated with fatigable ptosis, which is most obvious when the patient is tired.

    Third nerve palsy will cause constant ptosis (unless surgically corrected).
    It is crucial to determine whether the pupil is affected in a patient with a third nerve palsy as
    this strongly suggests a compressive or traumatic lesion.

    Ask about symptoms related to hyper/hypothyroidism if you suspect dysthyroid eye disease.

    Pupil reactions
    When examining the pupils it is important to check whether the pupils are equal or unequal at
    the outset of the examination.
    Equal pupils indicate an afferent (sensory) defect – usually in the optic nerve.
    Unequal pupils indicate a motor defect
    If the larger pupil reacts briskly to light the smaller pupil is probably the abnormal one.
    • Physiological anisocoria
    • Horner syndrome (~2mm ptosis)
    • Third nerve palsy
    • Adie pupil
    • Argyll-Robertson pupil
    • Miotics and mydriatics

    www.passpaces.co.uk Tel: 07 971 971 000

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