Summary of Common Conditions Seen in OSCEs
| Condition | Findings on examination | Management |
| Diabetic retinopathy | Background retinopathy: blot haemorrhages, microaneurysms, hard exudates Pre-proliferative: cotton wool spots, intraretinal microvascular abnormalities (IRMAs), venous loops Proliferative: new vessels at disc or elsewhere Maculopathy: exudates at macula | Regular referral to ophthalmology if background retinopathy All other findings require urgent referral Tighter control of diabetes: conservative and medical management |
| Hypertensive retinopathy | Grade 1: Silver wiring Grade 2: Arteriovenous nipping Grade 3: Flame haemorrhages, cotton wool spots Grade 4: Papilloedema Macular star | Antihypertensive (oral and intravenous) Grades 3 and 4 are regarded as medical emergencies If hypertension is refractive to treatment, look for rarer causes:
|
| Optic atrophy | Pale optic disc | Investigate for a cause and treat accordingly:
|
| Papilloedema | Raised disc Blurred disc margin | Treat cause: hypertension, raised intracranial pressure |
| Age-related macular degeneration (AMD) | Elderly patient Drusen at macula New vessels (neovascularisation) – wet AMD | Urgent ophthalmology referral Dry AMD: No treatment. Smoking may be a risk factor Wet AMD: Intravitreal anti-VEGF |
| Retinitis pigmentosa | Black specks following retinal veins Optic atrophy Cataract | Urgent ophthalmology referral No treatment is available Genetic counselling may be appropriate for inherited forms |
| Central retinal artery occlusion | Pale retina Cherry red spot on macula | Urgent ophthalmology referral No treatment is available Look for a cause:
|
| Central retinal vein occlusion | Haemorrhages along venous distribution Partial areas may be affected from retinal vein branch occlusion ‘Stormy sunset’ | Urgent ophthalmology referral Treat cause:
|
| Cataract | Absence (partial or complete) of red reflex | If early onset, investigate for a cause: congenital infection, hyperparathyroidism, corticosteroids Treatment: Cataract removal and implantation of intraocular lens |
Hints and Tips for the Exam
Ophthalmoscopy is a difficult technique to master. Under the pressure of an OSCE, those who have neglected to practise this station sufficiently are likely to unravel.
Communication, Communication, Communication …
As with many of the stations, your opening communication with the patient is absolutely fundamental, and that starts with your introduction and explanation of the examination. You can avoid making them anxious by explaining that you will be getting very close to them, resting your thumb on their eyebrow, and shining a very bright light in their eye. Add that they should look at a point on the wall and try to keep still; if they become uncomfortable at any point, the examination can be stopped.
Get Your Technique Right
Try to familiarise yourself with the ophthalmoscope used at your medical school. First test the light from the ophthalmoscope by shining it onto the back of your hand. Then assess for a red reflex by looking through the scope at the patient’s eyes while standing at approximately 15 degrees from the midline. At this point, the lens on the scope should be set to zero. You should only start to focus the lens as you move in towards the patient.
Remember to use your right hand with your right eye to look into the patient’s right eye (and vice versa). A common mistake is to stand too far from the midline.
Be Clear and Systematic When Describing Your Findings
You will probably have to examine a model in which various retinal slides have been placed. Be sure to look carefully into both eyes as different pathologies might be presented. To maximise your marks, give your description in the following order:
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