OPTOMETRY COUNCIL OF AUTRALIA AND NEW ZEALAND Competency in Optometry Examination FIRST PAPER 11 SEPTEMBER 2007 Perusal time:

10 minutes Time allowed: THREE hours Candidates should answer ALL questions. All questions are of equal value.

1.

A 2-year-old male patient is brought to you for an examination and your retinoscopy finding is: R +2.00 DS L +1.25 / -5.00 x 10 How would you explain to this patients mother the reasons why this refractive finding should be dispensed to the patient? (10 marks)

2.

A 31-year-old female patient presents to you complaining of itchy eyes. List clinical procedures that you would use to investigate this complaint, in the order that you would perform them in your consultation, and briefly describe the rationale for using the procedures. (10 marks)

3.

Your 22-year-old female patient has presented with a red eye. This was present on waking the previous day, with a pricking sensation in the eye. She now has some light discomfort and watering in this eye which was not present previously. General health is reported as normal. Biomicroscopy reveals a clear cornea and anterior chamber. There is a marked red appearance to the nasal conjunctiva, with hyperaemia and dilated episcleral vessels. The vessels blanch with phenylephrine. The palpebral and tarsal conjunctivae are normal. Pupil reactions are normal. Visual acuity is 6/6 each eye. a) What is a likely diagnosis? (2 marks)

b) The patient is concerned regarding the redness and discomfort. How might this be treated? Assume unrestricted access to therapeutic agents in your answer. (4 marks) c) If this was the third occurrence rather than the first of this condition, how might management differ? (4 marks)

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4.

You are examining a 25-year-old man who is noticing episodes of vertical double vision more frequently over the past few months, and worse with reading. He also tilts his head to one side. Motility testing shows depression of the right eye is restricted when looking down and to the right, and his right eye elevates in left gaze. Heterophoria testing reveals an 8 R hypertropia in the primary position. a) b) c) d) e) What extraocular muscle is most likely affected? What other clinical testing could be done to confirm this? Describe and explain results that would confirm the diagnosis. Explain why the left eye elevates in right gaze. What is his likely habitual head tilt? (1 mark) (2 marks) (4 marks) (2 marks) (1 mark)

5.

Explain how you would set up a slit lamp biomicroscope to examine the corneal endothelium. (4 marks) b) Describe the changes that you would expect to see in the endothelium in: i) Fuchs corneal dystrophy. (3 marks) ii) long-term wear of low water content, low oxygen-permeable contact lenses. (3 marks)

a)

6.

The two most commonly used ocular stains are sodium fluorescein and rose bengal. a) What is revealed on the ocular surface when it is stained with sodium fluorescein? (2 marks) b) What illumination source and observation filters should be used when observing an eye stained with sodium fluorescein? (2 marks) c) What is revealed on the ocular surface when it is stained with rose bengal? (2 marks) d) What illumination source should be used when observing an eye stained with rose bengal? (2 marks) e) Give a brief account of some other clinical applications of sodium fluorescein. (2 marks)

7.

Outline the major causes of dry eye, and the clinical assessments that can be used to differentiate those causes. (10 marks) A patient presents to you with a history of a tumour of the left temporal lobe. Use well-labelled diagrams to illustrate the visual field results you would expect to find in this patient. (5 marks) b) Explain your answer with reference to your understanding of the anatomy of the visual pathways. (5 marks) a)

8.

9.

a) The case history is very important for a child with vision-related learning problems. Discuss some of the chief complaints/concerns and symptoms and signs that may be associated with learning problems. (5 marks) b) Outline the essential examination procedures that you would include to evaluate a child who presents to your practice with a history of learning difficulties. (5 marks)

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10. A 59-year-old male patient presents for examination complaining of difficulty with distance vision over the past few weeks. However, he has no difficulty with reading books and other near tasks. His distance vision with his current multifocals is R 6/12- and L 6/9-. Refraction shows that his R distance prescription has altered by -0.75/-0.50x75 and his L distance prescription has altered by -0.75/-0.25x90 to give visual acuities of R 6/5 and L 6/5-. His near addition remains unchanged. a) Indicate possible differential diagnoses. (2 marks) b) What other information might be necessary from the case history to assist in managing this patient? (3 marks) c) What further tests or actions would be appropriate to differentially diagnose and manage this patient? Summarise findings that would support each differential diagnosis. (5 marks)

11. A 42-year-old man presents for routine examination complaining of near vision difficulties over the past six months. He reports no other symptoms. He reports that he has had blows to the eye, which caused significant black eyes, on a number of occasions during the playing of contact sports and in his occupation as a police officer. Apart from the need for a presbyopic correction, refractive and binocular vision examination was unremarkable. Unaided distance vision was R 6/6 and L 6/6. Colour vision is normal. a) c) List potential areas of concern from this patients history. Indicate your advice to the patient regarding his history. (3 marks) (5 marks) (2 marks)

b) What other clinical tests would be appropriate for this patient?

12. Your patient, who is asymptomatic and presenting for routine examination, is found on slit-lamp biomicroscopy to have vortex keratopathy. Discuss any potential implications of this if: a) your patient is a 35-year-old female, and the vortex keratopathy is present also in her 10-year-old daughter and 12-year-old son. (6 marks) b) your patient is a 65-year-old male taking medication for cardiac arrhythmia. (4 marks)

13. A 28-year-old woman complains of red, irritated eyes with watery discharge over the past 7 weeks. On slitlamp examination you find a follicular conjunctivitis. a) What are the differential diagnoses? Name three (3). (3 marks) b) What specific questions would you include in your case history for each of the three (3) differential diagnoses? (3 marks) c) On slit-lamp examination, you find an umbilicated nodule on the superior lid margin. What is the most likely diagnosis? (2 marks) d) What would be your management plan? (2 marks)

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14. A 50-year-old female patient consults you. She reports that she is currently being treated for a pituitary tumour. She asks whether she will be eligible for driving a private vehicle. a) What are the legal requirements for driving in Australia? (4 marks)

b) What tests would you undertake to determine her eligibility for driving and what aspects of her condition are likely to be important in relation to driving eligibility? (6 marks)

15. A 60-year-old male patient presents to you with a three day history of flashes and floaters. a) Outline the specific examination techniques that you would use for exploring the cause of these symptoms in this patient. (4 marks)

b) Name two (2) potential causes of these symptoms and your management plan for each of them, including your advice to the patient and the relative urgency of your referral or review. (6 marks)

16. What factors would you consider when determining whether to refer a patient to an ophthalmologist for pterygium removal? (10 marks)

17. A 60-year-old man consults you and you diagnose primary open-angle glaucoma. His visual fields show a small arcuate loss in both eyes and on ophthalmoscopy you observe an arcuate nerve fibre layer defect. His intraocular pressures are 27 mmHg in each eye. This man also suffers from asthma, is a diabetic and has an allergy to sulphur drugs. a) c) What anti-glaucoma medications could be prescribed? Are any medications contraindicated here and why? (3 marks) (3 marks) (4 marks)

b) How can their effectiveness be assessed?

18. A 10-year-old girl is brought to your practice as she is reporting difficulty in seeing the board at school. You suspect that the child may be malingering. What clinical procedures might you use to determine if the patient was malingering or not? (4 marks) b) Assuming that you do NOT confirm the above diagnosis, what would be your next step in managing this patient? (3 marks) c) If the cause of the poor distance vision is found to be a NON-refractive vision impairment, what other support services may be appropriate for this patient? (3 marks) a)

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