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Clinical decision-making: Part 1.

Readers are encouraged to discuss the cases in this FREE VRICS with their colleagues, conduct simple Internet searches, and use the references provided to complete the Multiple Choice Questions (MCQs). Please note that there is only one correct answer for each MCQ. Complete the VRICS test online at:


0l What is the MOST accurate description of the clinical finding shown in Image A?

a Marked anterior blepharitis

b Moderate lower lid entropian

c Inferior corneal staining and moderate posterior blepharitis

d Lower lid chalazion

02 Which of the following is FALSE in relation to the clinical assessment of the condition shown in Image A?

a Tear break-up time (TBUT) is not relevant to investigating the severity of this condition

b Fluorescein stain should be used to detect and assess the extent of corneal epithelium compromise

c Examination of the height and regularity of the tear meniscus provides useful information about the tear film quality

d Careful examination of the lids and lashes with a slit lamp is vital in determining the extent and severity of this condition

03 Which of the following does NOT make up part of the treatment strategy for the condition shown in Image A?

a Lid and lash cleaning through hot compresses and lid cleaning regime

b Referral for the prescription of an oral steroid to reduce inflammation in severe cases

c Artificial tears and ocular lubricants to maintain comfort and aid corneal epithelium regeneration

d Referral for prescription of oral doxycycline in severe cases which are unresponsive to first line treatments

Reference to aid completion of the case

a) College of Optometrists Clinical Management Guidelines--Blepharitis. management_guidelines/index.cfm b) b)


04 What is the MOST accurate description of the lesion shown in Image B?

a Cyst of Zeiss on the left lower lid

b Basal cell carcinoma of the left eye

c Larger lower lid chalazion

d Cyst of Moll on the left lower lid

05 Which of the following is false in relation to the Image?

a High exposure and fair skin type are risk factors for its development

b This lesion is completely benign

c The majority of these occur on the lower eyelid

d This is a malignant tumour with the potential of invading locally adjacent tissues

06 Which of the following statements is TRUE in relation to the treatment of the lesion shown in Image B?

a No treatment is required as this tends to resolve spontaneously

b Cryotherapy is the most common and successful modality of treatment

c Surgical excision of the lesion with Mohs surgery is the treatment of choice

d The lesion should be photographed and monitored within optometric practice

Reference to aid completion of the case

a) Fong KCS, Malhotra R (2005) Common eyelid malignancies: Clinical features and management options. Optometry Today, 45 (November 18): pp30-34 b) College of Optometrists Clinical Management Guidelines--Basal Cell Carcinoma.


07 Which of the following statements regarding the clinical finding shown in Image C is FALSE?

a There is a degree of anisocoria between these two eyes

b The right pupil is small in relation to the left pupil

c It is impossible to deduce which pupil is affected without examining the reactions to light

d There is slight ptosis of the left upper lid

08 Which of the following statements in relation to the clinical finding shown in Image C is FALSE?

a Prompt referral to an ophthalmologist for investigation of the underlying cause is vital

b This can occur in association with a third nerve palsy

c The patient does not need to be referred as they can be monitored within practice

d This finding might be caused by trauma, tumour or cardiovascular accident

09 If the left pupil is unresponsive to light and appears as shown in Image C, which of the following is TRUE?

a There is RAPD due to optic nerve damage in the left eye

b There is a right Adie's pupil due to parasympathetic dysfunction

c There is physiological aniscoria present

d There is a left Horner's syndrome due to sympathetic dysfunction

Reference to aid completion of the case

a) Kipioti T (2013) Demystifying Pupil Anomalies. Optometry Today, 53 (February 22): pp52-56, february_2013_kipioti.pdf


l0 What is the MOST accurate description of the defect shown in Image D?

a Moderate inferior arcuate defect

b Marked superor altitudinal defect

c Superior nasal step

d Inferior paracentral scotoma

11 What is the MOST likely cause of the defect shown in Image D?

a A lesion at a post-chiasmal location in the visual pathway

b Marked atrophy of the inferior neuro-retinal rim of the right optic disc

c Central retinal vein occlusion in the left eye

d Marked atrophy of the superior neuro-retinal rim of the left optic disc

12 In relation to the investigation and management of a patient with the defect shown in Image D, which of the following is FALSE?

a Prevention of progressive loss is not important as the patient will be less aware of the defect due to the location

b Topical medical treatment is likely to be used to modify the IOP to a level where progression does not continue

c Surgery may be required to achieve long-term control, in order to prevent further progression

d The anterior segment of the eye requires detailed examination, including gonioscopy, to establish the diagnosis

Reference to aid completion of the case

Clinical decision making 1--'visual field interpretation',


* EXAM QUESTIONS Under the new enhanced CET rules of the GOC, answers to MCQs for this exam must be submitted online. Please visit and complete by midnight on June 28, 2013. You will be unable to submit exams after this date. Answers will be published on and CET points will be uploaded every two weeks. You will then need to log into your CET portfolio by clicking on "MyGOC" on the GOC website ( to confirm your points.

* REFLECTIVE LEARNING Having completed this CET exam, consider whether you feel more confident in your clinical skills--how will you change the way you practice? How will you use this information to improve your work for patient benefit?

Stanley Keys, BSc (Hons), FCOptom, Dip Glauc, Dip Tp (IP)

About the author

Stanley Keys is principal optometrist and clinical teacher at Ninewells Hospital in Dundee. He also works in private optometric practice. He has gained independent prescribing status as well as the College Diploma in Glaucoma. He is also active in optometric education, having authored CET and through his work with NHS Education Scotland and as vice-chair of Acuity Scotland. He is a fellow of the College of Optometrists.

Visit for all the information about Enhanced CET requirements
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Author:Keys, Stanley
Publication:Optometry Today
Geographic Code:4EUUK
Date:May 17, 2013
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