Full Chapter Viva and Osce Exams in Ophthalmology A Revision Study Guide Timothy H M Fung PDF

Viva and OSCE Exams in
Ophthalmology A Revision Study Guide

Timothy H. M. Fung
Visit to download the full and correct content document:
https://textbookfull.com/product/viva-and-osce-exams-in-ophthalmology-a-revision-stu
dy-guide-timothy-h-m-fung/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
PHR and SPHR Professional in Human Resources

Certification Complete Study Guide 2018 Exams Reed
https://textbookfull.com/product/phr-and-sphr-professional-in-
human-resources-certification-complete-study-guide-2018-exams-
reed/
Water operator certification study guide a guide to

preparing for water treatment and distribution operator
certification exams Giorgi
https://textbookfull.com/product/water-operator-certification-
study-guide-a-guide-to-preparing-for-water-treatment-and-
distribution-operator-certification-exams-giorgi/
OSCEs for the MRCS Part B: A Bailey & Love Revision

Guide Jonathan M. Fishman
https://textbookfull.com/product/osces-for-the-mrcs-part-b-a-
bailey-love-revision-guide-jonathan-m-fishman/
The Definitive Guide to the OSCE: The Objective

Structured Clinical Examination as a performance
assessment Ronald M. Harden
https://textbookfull.com/product/the-definitive-guide-to-the-
osce-the-objective-structured-clinical-examination-as-a-
performance-assessment-ronald-m-harden/
RHCSA/RHCE Red Hat Linux certification study guide :
(exams EX200 & EX300) Seventh Edition Jang
https://textbookfull.com/product/rhcsa-rhce-red-hat-linux-
certification-study-guide-exams-ex200-ex300-seventh-edition-jang/
RHCSA RHCE Red Hat Linux certification study guide

exams EX200 EX300 Seventh Edition Jang
https://textbookfull.com/product/rhcsa-rhce-red-hat-linux-
certification-study-guide-exams-ex200-ex300-seventh-edition-
jang-2/
Geography for the IB Diploma Study and Revision Guide

HL Core HL Core Extension Simon Oakes
https://textbookfull.com/product/geography-for-the-ib-diploma-
study-and-revision-guide-hl-core-hl-core-extension-simon-oakes/
Memorizing Medicine: A Revision Guide 2nd Edition Paul

Bentley
https://textbookfull.com/product/memorizing-medicine-a-revision-
guide-2nd-edition-paul-bentley/
Questions and Answers in Pain Medicine: A Guide to

Board Exams 1st Edition Michael Suer
https://textbookfull.com/product/questions-and-answers-in-pain-
medicine-a-guide-to-board-exams-1st-edition-michael-suer/
Viva and OSCE
Exams in
Ophthalmology
A Revision Study Guide
Timothy H. M. Fung
Winfried M. K. Amoaku
Editors
123
Viva and OSCE Exams in Ophthalmology
Timothy H. M. Fung
Editors
Viva and OSCE Exams

in Ophthalmology
A Revision Study Guide
Editors
Timothy H. M. Fung Winfried M. K. Amoaku
Nottingham University Hospitals Nottingham University Hospitals
NHS Trust, Queen’s Medical Centre NHS Trust, Queen’s Medical Centre
Nottingham Nottingham
UK UK
Royal Derby Hospital University of Nottingham

Derby Nottingham
UK UK
ISBN 978-3-030-43062-7 ISBN 978-3-030-43063-4 (eBook)

https://doi.org/10.1007/978-3-030-43063-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2020
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface
There are numerous books and online resources that you may find useful in
preparation for the oral component of ophthalmology examinations. This par-
ticular book attempts to amalgamate all these resources together in one text.
We hope prospective candidates will find it useful in the preparation for their
examination, and subsequently as a reference text.
The book is aimed predominantly for those preparing for the FRCOphth
Part 2 Fellowship Oral Component. Each chapter of the book is therefore
based on a station of the FRCOphth Part 2 Fellowship Oral Component. We
have tried to cover all the essential topics required for the examination in an
accessible and concise way. We hope this book will also be useful for candi-
dates preparing for other ophthalmology membership or fellowship exams
and any allied health professionals who want to broaden their general oph-
thalmology knowledge base. For the latter candidates, the individual chapters
may not be an exact fit of their examination. However, the knowledge and
basic information of technique and preparations remain the same.
To all prospective candidates, we wish you every success in the examina-
tion and your future career and hope this book will contribute in some way to
your success.
Nottingham, UK Timothy H. M. Fung

Nottingham, UK Winfried M. K. Amoaku
v
Contents
Part I Structured VIVA
1 VIVA Technique: Do’s and Don’ts�� 3

Timothy H. M. Fung and Winfried M. K. Amoaku
1.1 Formalities�� 3
1.2 Answering Examiners Questions�� 3
1.3 Communications Skills (for the Communication
Skills Station)�� 3
1.4 When You Think Things Are Going Badly �� 4
2 Patient Investigations and Interpretation�� 5
2.1 Optical Coherence Tomography (OCT)�� 5
2.1.1 Principles�� 5
2.1.2 Indications�� 5
2.1.3 OCT Images of Common Macular Pathologies�� 5
2.1.4 OCT Images of Common Optic Nerve Pathologies�� 18
2.2 OCT-Angiography (OCT-A) �� 18
2.2.3 Limitations�� 18
2.3 Fundus Fluorescein Angiography (FFA)�� 18
2.3.3 Contraindications�� 20
2.3.4 Possible Side-Effects�� 20
2.3.5 Treatment of Anaphylaxis�� 20
2.3.6 Interpretation�� 20
2.3.7 Fluorescein Angioscopic Appearance of Common
Macular Disorders�� 23
2.4 Hess Chart�� 26
2.4.4 Distinguishing Neurogenic Palsies and Mechanical
Disorders of Ocular Motility on a Hess Chart�� 27
2.4.5 Hess Charts of Common Ocular Motility Disorders�� 27
vii
viii Contents
2.5 Computerised Tomography (CT)�� 27

2.5.4 Advantages�� 32
2.5.5 Disadvantages �� 32
2.5.7 CT Scan Images of Common Orbital Disorders
Occurring in Adults�� 33
2.5.8 CT Scan Images of Common Orbital Disorders
Occurring in Childhood�� 36
2.6 Magnetic Resonance Imaging (MRI)�� 36
2.6.7 MRI Images on Orbital Disorders Occurring
in Adulthood �� 38
2.6.8 MRI Images of Orbital Disorders Occurring
in Childhood �� 38
2.7 Humphrey Visual Field (HVF)�� 38
2.7.4 Detecting Glaucoma Progression�� 41
2.8 Field of Binocular Single Vision (BSV) �� 41
2.9 Corneal Topography�� 42
2.9.3 General Approach to Interpreting
Pentacam Printouts�� 43
2.9.4 Corneal Topography of Ectatic Disorders�� 45
2.10 Biometry �� 48
2.10.1 Optical Biometry�� 48
2.10.2 Ultrasound (A-Scan) Biometry �� 49
2.11 Dacryocystography (DCG) �� 52
2.11.4 DCG Images of Common Pathologies of
the Lacrimal Drainage System�� 53
2.12 Dacryoscintigraphy (DSG) �� 53
Contents ix
2.13 Electrodiagnostic Tests �� 55

2.13.1 Full Field Electroretinogram (ERG) �� 55
2.13.2 Pattern ERG (PERG)�� 56
2.13.3 Multifocal ERG (mfERG)�� 57
2.13.4 Electrooculogram (EOG)�� 58
2.13.5 Visual Evoked Potential (VEP) �� 58
References�� 61
3 Patient Management in Clinical Practice�� 63
3.1 Non-Proliferative Diabetic Retinopathy (NPDR) �� 63
3.1.1 Other Diagnoses to Consider�� 63
3.1.2 Risk Factors for Diabetic Retinopathy (DR)�� 63
3.1.3 Classification�� 63
3.1.4 Examination�� 64
3.1.5 Investigations�� 64
3.1.6 Treatment�� 64
3.1.7 Follow-Up �� 65
3.1.8 Prognosis�� 65
3.2 Diabetic Macular Oedema (DMO) �� 65
3.2.1 Other Causes of Macular Oedema to Consider�� 65
3.2.6 Follow-Up �� 67
3.2.7 Focal and Grid Laser Techniques�� 67
3.3 Proliferative Diabetic Retinopathy (PDR) �� 68
3.3.1 Other Causes of Neovascularisation to Consider�� 68
3.3.2 High-Risk PDR �� 68
3.3.3 PDR in Pregnancy�� 68
3.3.6 PRP Laser Technique�� 69
3.4 Branch Retinal Vein Occlusion (BRVO) �� 70
3.4.2 Risk Factors�� 70
3.4.6 RCOphth RVO Guidelines 2015
Treatment Algorithm�� 72
3.5 Central Retinal Vein Occlusion (CRVO) �� 73
3.5.6 Follow Up �� 74
x Contents
3.5.7 RCOphth RVO Guidelines 2015

Treatment Algorithm�� 75
3.6 Cilioretinal Artery Occlusion (CLRAO) in a
Young Patient�� 76
3.6.1 Causes �� 76
3.7 Usher Syndrome�� 77
3.7.2 History�� 77
3.8 Rhegmatogenous Retinal Detachment (RD) �� 77
3.8.2 Retinal Tears �� 78
3.8.3 Lincoff Rules�� 78
3.8.4 History�� 79
3.8.8 The RCOphth Ophthalmic Services
Guidance for the Management of
Acute Retinal Detachment 2010 �� 80
3.9 Macular Hole (MH) �� 80
3.9.1 Differential Diagnosis �� 80
3.9.3 Causes �� 81
3.9.8 Prognostic Factors for Treatment of Idiopathic MH�� 82
3.9.9 Face Down Posturing for Idiopathic MH�� 83
3.9.10 Development of Idiopathic MH in Fellow Eyes �� 83
3.9.11 Success Rates for Idiopathic MH Closure�� 83
3.9.12 Post-Operative Complications of Surgery�� 83
3.10 Toxoplasmosis�� 83
3.10.2 History�� 83
3.11 Vogt-Koyanagi-Harada (VKH) Syndrome�� 84
Contents xi
3.12 Malattia Leventinese/Doyne Honeycomb
Retinal Dystrophy �� 85
3.13 Approach to the Adult Watering Eye�� 86
3.13.1 History�� 86
3.13.2 Differential Diagnosis of a Watery Eye in an Adult�� 86
3.13.3 Differential Diagnosis of a Tearing Eye in an Adult�� 87
3.13.7 Dacryocystorhinostomy (DCR)�� 89
3.14 Approach to the Paediatric Watering Eye �� 89
3.14.1 History�� 89
3.14.4 Congenital Nasolacrimal Duct
Obstruction (CNLDO) �� 91
3.15 Approach to the Patient with Proptosis�� 92
3.15.1 History�� 92
3.15.4 Orbital Disease Occurring in Adults �� 93
3.15.5 Orbital Diseases Occurring in Childhood �� 98
3.16 Approach to the Patient with Ptosis�� 102
3.16.1 Classification of Ptosis�� 102
3.16.2 History�� 104
3.17 Approach to the Patient with Vertical Diplopia�� 108
3.17.1 Diagnoses to Consider for Monocular
Vertical Diplopia �� 108
3.17.2 Diagnoses to Consider for Binocular
Vertical Diplopia �� 108
3.17.3 History�� 108
3.17.6 Restriction of Extraocular Motility in
Orbital Fractures �� 110
3.17.7 Restriction of Extraocular Motility in TED�� 111
3.18 Angle Closure �� 112
3.18.1 Risk Factors for Angle Closure�� 112
3.18.2 Mechanisms of Angle Closure�� 112
3.18.3 History�� 113
xii Contents

3.18.8 Management of Acute Angle Closure
(AAC) Attack�� 114
3.19 Normal Tension Glaucoma (NTG) �� 114
3.19.1 History�� 114
3.19.5 Risk Factors for Progression of NTG �� 116
3.20 Chronic Open Angle Glaucoma (COAG) �� 116
3.20.1 Risk Factors for COAG�� 116
3.20.2 History�� 116
3.20.5 Diagnosis�� 118
3.21 Aqueous Misdirection�� 120
3.21.1 Definition�� 120
3.21.3 History�� 120
3.22 Vernal Keratoconjunctivitis (VKC) �� 121
3.22.1 Associated Diseases�� 121
3.22.2 History�� 122
3.23 Atopic Keratoconjunctivitis (AKC) �� 124
3.23.1 History�� 124
3.24 Bacterial Keratitis �� 125
3.24.2 History�� 125
3.24.4 Investigation�� 125
3.25 Herpes Simplex Virus (HSV) Keratitis �� 126
3.25.1 History�� 126
3.25.4 Herpetic Eye Disease Study (HEDS)�� 127
Contents xiii
3.26 Acanthamoeba Keratitis�� 128

3.26.2 History�� 128
3.27 Fungal Keratitis�� 129
3.27.2 History�� 129
3.28 Ectopia Lentis �� 131
3.28.2 History�� 131
3.29 High Myopia and Cataract Surgery�� 132
3.29.1 Preoperative Considerations �� 132
3.29.2 Intraoperative Considerations �� 132
3.29.3 Postoperative Considerations�� 132
3.30 Pseudoexfoliation and Cataract Surgery �� 133
3.30.3 Postoperative Considerations�� 133
3.31 Intraoperative Floppy Iris Syndrome (IFIS) �� 133
3.31.1 Features �� 133
3.32 Corneal Endothelium in Cataract Surgery�� 134
3.32.1 Endothelial Cell Counts�� 134
3.32.2 Ophthalmic Viscosurgical Devices (OVDs)�� 134
3.32.3 Soft-Shell Technique�� 134
3.32.4 Ultimate Soft-Shell Technique�� 134
3.32.5 Irrigating Solutions �� 134
3.33 Endophthalmitis�� 135
3.33.3 Treatment of Acute Endophthalmitis�� 135
3.33.4 Prevention �� 136
3.34 The RCOphth Ophthalmic Services Guidance on
Managing an Outbreak of Post-Operative
Endophthalmitis 2016 �� 136
3.34.1 Outbreak Definition�� 136
3.34.2 Determine If There Is an Outbreak �� 136
3.34.3 Notification �� 136
xiv Contents
3.34.4 Immediate Measures �� 137

3.35 Idiopathic Intracranial Hypertension (IIH) �� 137
3.35.1 Differential Diagnosis of Disc Swelling �� 137
3.35.2 Causes of Raised ICP�� 138
3.35.3 Terminology�� 138
3.35.4 Criteria for Diagnosis of IIH�� 138
3.35.5 History�� 139
3.36 Septo-Optic Dysplasia (De Morsier Syndrome) �� 140
3.36.1 Risk Factors for Optic Nerve Hypoplasia �� 140
3.37 Tobacco-Alcohol Amblyopia�� 141
3.37.1 Pathophysiology�� 141
3.37.3 History�� 141
3.38 Optic Atrophy in Infancy and Childhood�� 142
3.38.1 Causes �� 142
3.38.2 History�� 142
3.39 Giant Cell Arteritis (GCA)�� 143
3.39.1 History�� 143
3.39.2 Examinations�� 143
3.39.4 Interpretation of Investigations �� 144
3.39.6 Complications �� 145
3.40 Comitant Esotropia (ET)�� 145
3.40.2 Classification of Comitant ET�� 146
3.40.3 Infantile ET �� 146
3.40.4 Accommodative ET�� 146
3.41 Comitant Exotropia (XT)�� 147
3.41.2 Classification of Comitant XT�� 147
3.41.3 Intermittent XT �� 147
3.42 Amblyopia Management�� 148
3.42.2 Methods of Detection�� 148
Contents xv
3.42.3 Methods of Treatment�� 148

3.43 Retinopathy of Prematurity (ROP)�� 149
3.43.1 Classification of ROP�� 149
3.43.2 UK ROP Guideline 2008�� 150
3.44 Penetrating Eye Injury�� 151
3.44.1 History�� 151
3.44.5 Tetanus Prophylaxis�� 152
3.45 Atypical Optic Neuritis �� 152
3.45.1 Features of Typical Optic Neuritis
(Acute Demyelinating Optic Neuritis)�� 152
3.45.2 Features of Atypical Optic Neuritis�� 152
3.45.3 Causes of Atypical Optic Neuritis�� 152
3.45.4 History�� 152
3.46 Carotid Artery Dissection �� 153
3.46.1 History�� 153
3.47 Transient Ischaemic Attack (TIA) and Stroke:
NICE Guidance [TA128]�� 154
3.47.1 Prompt Recognition of Symptoms of
Stroke and TIA�� 154
3.47.2 Assessment of People Who Have Had a
Suspected TIA, and Identifying Those at
High Risk of Stroke�� 154
3.47.3 Urgent Carotid Endarterectomy and
Carotid Stenting�� 155
3.47.4 Pharmacological Treatments for People with
Acute Stroke�� 155
3.48 Amaurosis Fugax (Table 3.36)�� 155
3.48.1 Causes �� 155
3.48.2 History�� 156
3.49 Juvenile Idiopathic Arthritis (JIA) �� 156
3.49.1 International League of Associations of
Rheumatologists Classification�� 156
3.49.2 Risk Factors for Developing Uveitis in JIA�� 157
xvi Contents
3.49.6 BSPAR and the RCOphth Guidelines for

Screening for Uveitis in JIA 2006�� 158
3.50 Paediatric Cataract�� 158
3.50.1 History�� 158
References�� 160
4 Attitudes, Ethics and Responsibilities in Clinical Practice�� 167
4.1 GMC Guidance: Doctors Use of Social Media 2013�� 167
4.1.1 Facebook: Patient Asking to Add You As a
Friend on Facebook�� 167
4.1.2 Facebook: Posting Messages on a Groups
Facebook Page�� 167
4.1.3 Twitter: Doctor Tweeting Messages on Twitter�� 168
4.2 GMC Guidance — Consent: Patients and Doctors Making
Decisions Together 2008�� 168
4.2.1 Patients Who Lacks Capacity to Consent �� 169
4.2.2 Delegating Consent�� 170
4.2.3 Capacity in Children �� 170
4.2.4 Children Refusing Treatment�� 170
4.3 GMC Guidance — Confidentiality: Good Practice in
Handling Patient Information 2017�� 171
4.3.1 Breaching Patient Confidentiality �� 171
4.4 GMC Guidance: Financial and Commercial
Arrangements and Conflicts of Interest 2013 �� 172
4.5 GMC Guidance: Revalidation�� 172
4.6 GMC Guidance: Appraisal�� 173
4.7 UK Government Guidance:
Parental Rights and Responsibilities�� 173
4.8 UK Government Guidance: Driving Eyesight Rules�� 173
4.9 UK Government Guidance: Registering Vision
Impairment as a Disability�� 174
4.10 UK Government Guidance: Data Protection Act 2018�� 174
4.11 UK Government Guidance — Safeguarding Policy:
Protecting Vulnerable Adults and Children�� 175
4.12 Never Events �� 175
4.13 Non-Accidental Injury (NAI)�� 176
4.14 Approach to Patient with Refractive Surprise�� 177
4.14.1 Verify the Problem�� 177
4.14.2 Case Note Review�� 177
4.14.3 Clinical Examination�� 177
4.15 Consenting for Cataract Surgery�� 178
4.16 Clinical Supervision of Trainees in Difficulty�� 178
Contents xvii
4.17 The RCOphth Ophthalmology Service Guidance on

Theatre Procedures 2018�� 180
4.18 Needle Stick Injury �� 184
4.18.1 Transmission Rates �� 184
4.18.2 Management�� 184
4.19 Ophthalmia Neonatorum�� 185
4.19.2 Causes �� 185
4.19.3 Chlamydia/Gonorrhoea�� 186
Suggested Reading�� 186
5 Health Promotion, Audit, Research and
Evidence-Based Medicine�� 189
5.1 Steroids �� 189
5.2 Trials in Glaucoma Involving Trabeculectomy�� 192
5.2.1 Collaborative Initial Glaucoma Treatment Study
(Lichter et al. 2001)�� 192
5.2.2 Advanced Glaucoma Intervention Study
(The AGIS Investigators 1998, 2001) �� 193
5.2.3 Tube Versus Trabeculectomy (TVT) Study
(Gedde et al. 2012)�� 194
5.2.4 Primary Tube Versus Trabeculectomy (PTVT)
Study (Gedde et al. 2018) �� 194
5.3 The RCOphth Guideline on Standards for the
Retrieval of Human Ocular Tissue Used in
Transplantation, Research and Training 2008�� 195
5.4 Recent Pivotal Age-Related Macular
Degeneration Clinical Trials �� 198
5.4.1 ANCHOR Study (Brown et al. 2006) �� 198
5.4.2 MARINA Study (Rosenfeld et al. 2006)�� 199
5.4.3 PrONTO Study (Fung et al. 2007)�� 199
5.4.4 PIER Study (Regillo et al. 2008)�� 200
5.4.5 The Comparison of Age-Related Macular
Degeneration Treatment Trial
(The CATT Research Group 2011)�� 201
5.4.6 VIEW 1 and VIEW 2 Studies (Heier et al. 2012) �� 202
5.4.7 Inhibition of VEGF in Age-Related Choroidal
Neovascularisation (IVAN) Trial
(Chakravarthy et al. 2013)�� 203
5.4.8 HAWK and HARRIER (Dugel et al. 2020)�� 203
5.4.9 The Age-Related Eye Disease Study
(Age-Related Eye Disease Study Group 2001)�� 204
5.4.10 The Age-Related Eye Disease Study 2
(The Age-Related Eye Disease Study 2 (AREDS2)
Research Group 2013)�� 205
5.5 The Optic Neuritis Treatment Trial (ONTT)�� 205
5.6 Principles of Screening Applied to the NHS Diabetic
Eye Screening Programme�� 206
xviii Contents
5.7 Public Health England NHS Diabetic Eye Screening

Programme (DESP) (Table 5.3)�� 207
5.7.1 NHS DESP Grading Definitions for
Diabetic Retinopathy�� 207
5.7.2 NHS DESP Grading Definitions for Diabetic
Maculopathy �� 208
5.7.3 NHS DESP Referral Criteria to
Hospital Eye Service (HES)�� 208
5.7.4 Treatment Time at HES�� 208
5.8 Diabetic Retinopathy Clinical Research Network
(DRCR.net) Protocols �� 208
5.9 Hydroxychloroquine and Chloroquine Retinopathy�� 209
5.9.1 Pathogenesis�� 209
5.9.2 History�� 209
5.9.5 The RCOphth Clinical Guidelines on
Hydroxychloroquine and Chloroquine Retinopathy:
Recommendations on Screening 2018�� 210
5.10 The RCOphth Review of the Ocular Side Effects
of Topiramate 2010 �� 211
5.10.2 Ocular Side-Effects �� 211
5.10.3 Recommendations�� 211
5.11 The Ocular Side-Effects of Vigabatrin (Sabril)
Information and Guidance for Screening
(The RCOphth 2008a)�� 211
5.11.1 Indications for Vigabatrin �� 211
5.11.2 History�� 212
5.11.6 Screening�� 212
5.12 Uveitis �� 212
5.12.1 Classification of Uveitis�� 212
5.12.2 The SUN Working Group Grading Scheme of
Anterior Chamber Cells�� 212
5.12.3 The SUN Working Group Grading Scheme for
Anterior Chamber Flare�� 213
5.12.4 Nussenblatt Scale for Vitreous Haze 1985�� 213
5.12.5 The SUN Working Group Activity of
Uveitis Terminology 2005�� 213
5.12.6 NICE Guidance [TA460] on Adalimumab�� 213
5.12.7 NICE Guidance [TA460] on Ozurdex�� 213
5.13 Creutzfeldt-Jakob Disease (CJD)�� 214
5.14 The RCOphth Ophthalmic Services Guidance on
Ophthalmic Instrument Decontamination 2016�� 214
Contents xix
5.15 The RCOphth Ophthalmic Services Guidance on the

Prevention of Transmission of Blood-Borne Viruses in
Ophthalmic Surgery�� 216
5.16 Audit �� 217
5.17 Laser Safety in Hospitals�� 217
6 Communication Skill Scenarios�� 221
Timothy H. M. Fung, Delicia Jayakumar, and
6.1 Explaining a Diagnosis to Patients/Parents�� 221
6.1.1 Scenario 1�� 221
6.1.2 Scenario 2�� 222
6.2 Discussing Management with Patients/Parents�� 223
6.2.1 Scenario 1�� 223
6.2.2 Scenario 2�� 224
6.2.3 Scenario 3�� 225
6.2.4 Scenario 4�� 226
6.3 Explaining Surgical Complications�� 227
6.3.1 Scenario�� 227
6.4 Explaining Surgical Errors�� 227
6.5 Consent for Treatment�� 228
6.5.1 Scenario 1�� 228
6.5.2 Scenario 2�� 229
6.6 Encouraging Compliance with Treatment�� 230
6.7 Communicating with Angry Parents�� 230
6.8 Breaching Confidentiality in the Public Interest�� 231
Part II Objective Structured Clinical Examination (OSCE)
7 Objective Structured Clinical Examination (OSCE)

Technique: Do’s and Don’ts�� 235
7.1 Formalities�� 235
7.2 Practice Examination Routines �� 235
7.3 Equipment �� 235
7.4 What the Examiners Are Looking For�� 236
7.5 Examining Patients �� 236
7.6 Examining and Presenting�� 236
7.7 Answering Examiners Questions�� 236
7.8 When You Think Things Are Going Wrong�� 237
xx Contents
8 Anterior Segment �� 239

8.1 Anterior Segment Examination Sequence�� 239
8.2 Epithelial Basement Membrane Dystrophy (EBMD) �� 240
8.2.1 History�� 240
8.3 Meesman Dystrophy �� 240
8.3.1 History�� 240
8.4 Reis-Buckler Dystrophy�� 241
8.4.1 History�� 241
8.5 Lattice Dystrophy�� 242
8.5.1 History�� 242
8.6 Granular Dystrophy�� 243
8.6.1 History�� 243
8.7 Macular Dystrophy �� 243
8.7.1 History�� 243
8.8 Avellino Dystrophy �� 244
8.8.1 History�� 244
8.9 Schnyder’s Crystalline Dystrophy (SCD) �� 244
8.9.1 History�� 244
8.10 Posterior Polymorphous Corneal Dystrophy (PPCD) �� 245
8.10.1 History�� 245
Contents xxi

8.11 Fuchs Endothelial Dystrophy (FED) �� 246
8.11.1 History�� 246
8.12 Interstitial Keratitis (IK) �� 248
8.12.1 Causes of IK�� 248
8.12.2 History�� 248
8.13 Lipid Keratopathy �� 250
8.13.1 Causes �� 250
8.14 Radial Keratotomy (RK) �� 251
8.14.2 Indications of RK�� 251
8.14.3 Complications of RK�� 251
8.15 Vortex Keratopathy �� 251
8.15.1 History�� 251
8.16 Calcific Band Keratopathy (BK) �� 252
8.16.1 Causes of BK�� 252
8.16.2 History�� 253
8.17 Infectious Crystalline Keratopathy (ICK) �� 253
8.17.1 History�� 253
8.18 Bullous Keratopathy �� 255
8.18.1 Causes �� 255
8.19 Salzmann Nodular Degeneration�� 256
8.19.1 Causes �� 256
xxii Contents
8.19.2 History�� 256

8.20 Laser In-Situ Keratomileusis (LASIK) �� 257
8.20.1 LASIK Surgical Technique�� 257
8.20.2 Complications of LASIK�� 257
8.21 Keratoconus (KC) �� 258
8.21.1 Associations of KC �� 258
8.21.2 History�� 258
8.22 Ocular Cicatricial Pemphigoid (OCP) �� 260
8.22.1 Causes of Symblepharon Formation�� 260
8.22.2 History�� 260
8.23 Penetrating Keratoplasty (PK)�� 262
8.23.5 Advantages of PK �� 262
8.23.6 Disadvantages of PK�� 262
8.23.8 Risk Factors for Immunologic Rejection
(Poor Prognostic Factors) �� 264
8.23.9 Penetrating Keratoplasty in Children�� 264
8.24 Deep Anterior Lamellar Keratoplasty (DALK)�� 264
8.24.5 Advantages of DALK �� 265
8.24.6 Disadvantages of DALK �� 265
8.25 Descemet Stripping Automated Endothelial
Keratoplasty (DSAEK) �� 265
8.25.5 Advantages of DSAEK �� 266
8.25.6 Disadvantages of DSAEK�� 266
Contents xxiii
8.26 Anterior Scleritis�� 266

8.26.1 Associations of Scleritis�� 266
8.26.2 History�� 267
8.27 Limbal Epithelial Stem Cell (LESC) Deficiency�� 268
8.27.1 Causes �� 268
8.27.2 History�� 268
8.28 Gundersen Flap �� 269
9 Glaucoma and Lid�� 271
9.1 Pseudoexfoliation (PXF) Syndrome �� 271
9.2 Pigment Dispersion Syndrome (PDS)�� 272
9.2.1 Risk Factors for PDS�� 272
9.2.2 Risk Factors for Conversion of PDS to
Pigmentary Glaucoma�� 272
9.2.6 Role of PI in PDS/Pigmentary Glaucoma�� 273
9.3 Neovascular Glaucoma (NVG) �� 274
9.3.1 Causes of NVG �� 274
9.4 Primary Congenital Glaucoma (PCG) �� 275
9.5 Aphakic Glaucoma�� 275
9.5.1 Causes of Aphakia�� 275
xxiv Contents
9.5.2 Mechanism of IOP Elevation in Aphakia �� 275

9.5.3 Complications of Aphakia�� 276
9.6 Sturge-Weber Syndrome
(Encephalotrigeminal Angiomatosis) �� 276
9.7 Congenital Aniridia�� 277
9.7.1 History�� 277
9.8 Rieger Syndrome�� 279
9.8.1 History�� 279
9.9 Trabeculectomy�� 280
9.9.2 Description of Bleb Morphology�� 280
9.9.3 Complications and its treatment�� 280
9.10 Glaucoma Drainage Implants (GDI’s) �� 282
9.10.1 Types of GDI�� 282
9.10.2 Mechanism of action�� 282
9.10.4 Complications and its treatment�� 282
9.11 Minimally Invasive Glaucoma Surgery (MIGS) �� 283
9.11.1 Types of MIGS and Their Mechanisms of Action�� 283
9.12 Lid Examination Sequence �� 283
9.13 Ectropion�� 284
9.13.2 History�� 284
9.14 Entropion�� 285
9.14.2 History�� 286
9.15 Facial Nerve (CN VII) Palsy�� 287
9.15.1 Causes of CN VII palsy�� 287
9.15.2 History�� 287
Contents xxv

9.16 Simple Congenital Ptosis�� 288
9.16.1 History�� 288
9.17 Involutional Ptosis�� 289
9.17.1 History�� 289
9.18 Chronic Progressive External Ophthalmoplegia (CPEO) �� 289
9.18.1 History�� 289
9.19 Floppy Eyelid Syndrome�� 291
9.19.1 History�� 291
9.20 Dermatochalasis�� 291
9.20.1 History�� 291
9.21 Marcus-Gunn Jaw Winking Syndrome �� 292
9.21.2 History�� 293
9.22 Myasthenia Gravis�� 293
9.22.1 History�� 293
9.23 Basal Cell Carcinoma (BCC) �� 294
9.23.1 Classification of BCC �� 294
9.23.2 History�� 294
9.23.6 Referrals of BCCs into Secondary Care
(NICE Guidance [NG12])�� 295
9.24 Actinic Keratosis�� 297
xxvi Contents
9.25 Melanocytic Naevus�� 297

9.25.1 History�� 297
Reference �� 298
10 Posterior Segment�� 299
10.1 Posterior Segment Examination Sequence �� 299
10.1.1 Indirect Slit-Lamp Biomicroscopy�� 299
10.1.2 Indirect Ophthalmoscopy�� 299
10.2 Stargardt Disease�� 300
10.2.4 Other Diagnosis to Consider �� 301
10.3 Best’s Macular Dystrophy (BMD) �� 301
10.3.1 History�� 301
10.3.5 Staging of BMD�� 302
10.4 Sorsby Macular Dystrophy �� 302
10.4.1 History�� 302
10.5 Retinitis Pigmentosa (RP) �� 303
10.5.1 Classification �� 303
10.5.2 History�� 303
10.5.6 Syndromic RP �� 304
10.6 Sector Retinitis Pigmentosa (Sector RP) �� 304
10.6.1 History�� 304
10.7 Age-Related Macular Degeneration (AMD)�� 305
10.7.1 Classification of AMD�� 305
10.7.2 History�� 306
Contents xxvii
10.7.6 Defining Risk for the Development of

Advanced AMD�� 308
10.8 Peripapillary Choroidal Neovascular (CNV) Membrane�� 309
10.8.1 Causes of Peripapillary CNV Membrane�� 309
10.9 Myopic Macular Degeneration �� 310
10.10 Branch Retinal Vein Occlusion (BRVO) �� 311
10.10.3 Investigations
(RCOphth RVO July 2015 Guidelines)�� 312
10.10.4 Treatment�� 312
10.10.5 Prognosis �� 314
10.11 Central Retinal Vein Occlusion (CRVO) �� 314
10.11.4 Treatment�� 315
10.11.5 Follow up�� 316
10.11.6 Prognosis �� 316
10.12 Central Retinal Artery Occlusion (CRAO) �� 316
10.12.4 Treatment�� 317
10.13 Diabetic Retinopathy (DR) �� 318
10.13.1 Proposed International Clinical Diabetic
Retinopathy and Diabetic Macular
Edema Severity Scales 2003 �� 318
10.13.2 High-Risk PDR �� 318
10.13.3 Clinically Significant Macular Oedema (CSMO) �� 319
10.13.6 Treatment�� 320
10.13.7 Diabetic Retinopathy in the
Context of Cataract Surgery�� 322
10.13.8 Diabetic Maculopathy in the
Context of Cataract Surgery�� 322
10.14 Von Hippel Lindau (VHL) Syndrome�� 322
10.14.1 History�� 322
xxviii Contents

10.14.4 Treatment�� 323
10.15 Angioid Streaks�� 323
10.15.1 Causes of Angioid Streaks�� 323
10.15.4 Treatment�� 324
10.16 Optic Disc Pits�� 324
10.16.3 Treatment�� 325
10.17 Choroidal Folds�� 325
10.17.1 Causes of Choroidal Folds�� 325
10.17.4 Treatment�� 326
10.18 Choroideraemia�� 326
10.18.3 Treatment�� 326
10.19 X-Linked Retinoschisis�� 326
10.19.1 History�� 326
10.19.4 Treatment�� 327
10.19.5 Other Diagnosis to Consider �� 327
10.20 Macular Telangiectasia (MacTel) Type 2�� 327
10.20.3 Treatment�� 328
10.21 Birdshot Chorioretinopathy�� 328
10.21.3 Treatment�� 329
10.22 Presumed Ocular Histoplasmosis Syndrome (POHS) �� 329
10.22.3 Treatment�� 330
10.23 Toxoplasmosis�� 330
10.23.3 Treatment�� 331
Contents xxix
10.24 Multifocal Choroiditis and Panuveitis (MFC) �� 331

10.24.3 Treatment�� 332
10.25 Retinal Arterial Macroaneurysm�� 332
10.25.3 Treatment�� 332
10.26 Choroidal Naevus�� 333
10.26.3 Treatment�� 333
10.26.4 Other Diagnoses to Consider for a Pigmented
Choroidal Lesion�� 333
10.27 Coats Disease�� 334
10.27.3 Treatment�� 334
10.28 Choroidal Osteoma �� 335
10.28.3 Treatment�� 335
11 Strabismus and Orbit�� 339
11.1 Strabismus Examination Sequence �� 339
11.2 Cranial Nerve III Palsy �� 340
11.2.2 Discussion Points�� 341
11.3 Cranial Nerve IV Palsy �� 343
11.4 Cranial Nerve VI Palsy �� 345
11.5 Brown’s Syndrome�� 346
11.6 Duane’s Retraction Syndrome�� 347
xxx Contents
11.7 Restrictive Myopathy in TED �� 348

11.8 Orbit Examination Sequence�� 349
11.9 TED�� 350
11.10 Post Enucleation Socket Syndrome (PESS) �� 351
12 Neuro-Ophthalmology �� 353
12.1 Examination of Patients with Abnormal Pupils�� 353
12.1.1 Pupils Examination Sequence �� 353
12.1.2 Causes of a RAPD�� 353
12.1.3 Causes of Light-Near Dissociation �� 353
12.1.4 Differential Diagnosis of Anisocoria�� 354
12.1.5 Clinical Cases for Pupil Examination �� 354
12.2 Examination of Patients with Visual Fields Defects �� 356
12.2.1 Confrontation Visual Fields
Examination Sequence�� 356
12.2.2 Differential Diagnosis of Visual Field Defects �� 356
12.3 Examination of Patients with the Direct Ophthalmoscope �� 357
12.3.1 Direct Ophthalmoscopy Examination Sequence�� 357
12.3.2 Direct Ophthalmoscopy Clinical Cases�� 357
12.4 Examination of Patients with Ocular Motility Disorders �� 357
12.4.1 Ocular Motility Examination Sequence�� 357
12.4.2 Clinical Cases of Ocular Motility Disorders�� 358
12.5 Approach to Patients with Nystagmus�� 359
12.5.1 Description of Nystagmus�� 359
12.5.2 Classification of Nystagmus�� 360
12.5.3 Causes of Nystagmus�� 360
12.5.4 History�� 360
Another random document with
no related content on Scribd:
it made her desperate; getting up from her crouching position, she
sped across the hall, frightened by the echoes of her crutch and her
own feet, and threw herself with all her force against the great door,
making the chain swing and rattle.
“What’s that?” cried Mrs. Bean’s cheery voice in the distance.
And in a few moments the door leading to the kitchen was opened,
and the buxom housekeeper appeared.
“Oh, Mrs. Bean,” cried Freda, throwing herself into her arms and
speaking in a voice hoarse with fear, “this house is haunted!”
“Bless the poor child! you’re overtired, and you fancy things, my
dear,” she said soothingly. “All these old places are full of strange
noises, but you’ll soon get used to them.”
“But faces! I saw a face, a dreadful face, with long sharp teeth like
a death’s head; it was looking at me through the banisters, up there!”
And poor Freda, with her head still buried in Mrs. Bean’s plump
shoulder, pointed upwards with her finger.
“Oh, no, my dear, you didn’t. It was only your fancy. What you
want is to go to bed, and after a good night’s rest you’ll see no more
death’s heads.”
Mrs. Bean’s manner was so very quiet and matter-of-fact, and she
took the account of the appearance so unemotionally, that it
occurred to Freda to ask:
“Haven’t you heard of that face being seen before?”
“Well,” said the housekeeper, rather taken aback, “I believe I have
heard something about it.”
“And the doors, why do they lock of themselves?”
“Oh, that’s very simple,” answered the housekeeper quickly.
“That’s a patent invented by the Captain for the greater security of
the house when he didn’t live here himself. I will show you how to
open them.”
She crossed to the door of the dining-room, followed by Freda. But
it seemed to the girl that she listened a few moments, before
attempting to open it. Then she turned what looked like a little
ornamental button above the keyhole, and the door opened.
“That’s how it’s done; you see it’s perfectly simple.”
“Ye-es,” said Freda, “but it all seems to me very strange.”
Mrs. Bean laughed, and wanted the girl to amuse herself with a
book while she cleared away the tea-things.
But no sooner was the housekeeper’s broad back turned than
Freda was off her chair in a moment, and out of the kitchen to a door
which opened into the court-yard. As this door had no secret bolt,
she was speedily outside, under the gallery.
Fancying, that she heard voices to the left, Freda turned in that
direction, and presently saw Crispin standing ankle-deep in the
snow, looking up at the gallery above.
“Were you talking to some one, Crispin?” she cried.
He started at the sound of her voice, and came towards her with
impatient steps.
“What the d——l are you doing out here?” he asked angrily, with a
stamp of his foot on the ground.
“I came out to talk to you,” she answered. “I sha’n’t catch cold.”
“You’ll catch something worse than cold if you come wandering out
here at all hours of the night,” muttered Crispin roughly. “Nell must
keep you indoors.”
He came through the sheltered colonnade, stamping the snow off
his feet.
“You’re a very disagreeable man, Crispin,” said Freda, watching
him gravely. “You must have been very good to my father for him to
have kept you about him so long. It shows,” she went on
triumphantly, “that he must have been much more amiable than they
say. Do you know I think you only talk against him to tease me. But it
is horrible, now that he’s dead.”
Her voice sank on the last word, and the tears started again.
When Crispin answered, which was not at once, his voice was
scarcely so harsh as before, though he spoke rather scoffingly.
“Women are always full of fancies. I don’t wonder your father
couldn’t stand them!”
It was Freda’s turn to laugh now.
“Oh,” she cried, “then I knew him better than you after all. For he
loved one woman so well that he could never bear to look at another
after she died. And he left his own daughter among women, nothing
but women. And I believe that all those years he wouldn’t see me
because he thought I could never be good enough for her daughter. I
was lame, you see,” she added softly.
There was a long, long pause. Freda had managed to get on the
right side of rough Crispin. For he suddenly startled her by taking her
in his right arm with a sweeping embrace which nearly took her off
her feet, while he said huskily:
“Come in, there’s a dear child; you’re cold. You’re quite right, I’ll be
good to you for the sake of—— Well, for your own sake!”
He half led, half carried her along under the gallery and into the
house. Mrs. Bean, who was standing at the back door with rather an
anxious look upon her face, seemed relieved to see that they
returned in amity. Crispin took the girl into a long, low-ceilinged
room, where the furniture, in holland bags, was stacked up against
the walls. He led her before a large oil-painting of a lady, the charm
of whose gracious beauty, even the old-fashioned fourth-rate
portrait-painter had not been able wholly to destroy.
“I suppose you can guess who that is,” said Crispin.
“My mother,” said Freda softly.
“I believe the Captain thought a lot of this picture once. But for the
last few years his memory had grown a bit dim, and he remembered
bitter things better than sweet ones.”
Freda drew a little nearer to Crispin. She perceived by his tone
how strong the sympathy had been between him and her father. She
gave a little sigh, and they instinctively turned to each other and
exchanged glances of growing liking and confidence as they went
down the long room and crossed the hall to the dining-room. Crispin
turned up the lamp, and was about to refill his pipe when it occurred
to him to turn to the girl and say:
“You won’t be able to stand this indoors, I suppose?”
“Oh, yes, I shall. They smoked all the time in the kitchen, at the
‘Barley Mow.’ ”
“The ‘Barley Mow,’ eh? How did you get there?”
Freda told him the whole story of her journey, her sojourn at the
inn, the mysterious character they gave her father.
When she mentioned her friend who was connected with the
government, Crispin grew very attentive, and asked for a minute
description of him, at the end of which he said: “The scoundrel!
That’s the fellow who was sneaking about here this afternoon. If I’d
guessed——”
He did not finish his sentence, but he looked so black that Freda
hastened to get off the unpleasant subject, and rushed into a
description of her adventures at Oldcastle Farm. This, however,
proved even less pleasing. Crispin listened with a frown on his face
to her account of the kindness of the Heritages, and at last broke out
into open impatience.
“Mind,” said he sharply, “if those two young cubs come carnying
about here while I’m away—as they will do, my word on it—you are
not to let them inside the door on any pretence, remember that.”
“I wouldn’t let Robert in,” said Freda decidedly.
“No, nor Dick, either.”
“I should let Dick in,” said Freda softly.
Crispin sat back in his chair to look at her face, and perceived
upon it a rosy red flush.
“Now look here,” he said, like one trembling on the borders of a
great outburst of passion, “if you let Dick Heritage come fooling
about you here, I’ll shoot him through the head. Now you
understand.”
Freda looked up with a sudden flash of haughtiness.
“I am going back to the convent, Crispin, and these gentlemen are
nothing to me. But if I were going to stay in this house, I should see
whom I liked, for I should be the mistress here.”
If she had stabbed him he would not have been more surprised.
He held his pipe in his hand, and stared at her, unable at first to find
words. She, on her side, felt very uncomfortable as soon as the
outburst had escaped her. She felt that a confession had slipped out
against her will, and she hung her head, and looked into the fire,
hoping that the glow would hide her flaming cheeks.
“So you would be mistress here, would you?” he said. “And you
intend to go back to the convent? And I suppose you think your
father’s wishes nothing.”
“I don’t know what they were; and I shall never know now!”
“Well, I’ll tell you. His wishes were that you should remain here,
and call yourself mistress if you like, while I go away to manage his
property abroad for him.”
“But, Crispin, what could I do here? I should be miserable. I should
like a nun’s life, but not a hermit’s!”
“Oh, well, you’ll get used to it. Your father had a troop of
pensioners in the town here: you will have them to look after.”
“Crispin,” she said suddenly after a pause, in a whisper, “who do
you think it was that killed Blewitt?”
Crispin was rather startled by the question.
“Well,” he asked in his turn, looking stolidly at the fire, “who did
Barnabas Ugthorpe think it was?”
“Oh,” said Freda quickly, “he was wrong, altogether wrong. I told
him so.”
“And supposing he had been right, altogether right, your father
would be a murderer.”
Freda bent her head, but said nothing.
“What do you say to that?”
The girl burst out fierily:
“Why, that he was not a murderer! he was not, he was not! And I
wouldn’t believe it if—if everybody in England had been there!”
She kept her head up, and looked at him steadily, her eyes
flashing defiance. After a few moments he got up.
“You’re tired, and you’re very silly,” he said, huskily.
And, with a nod, but without again looking at her he left the room,
as Mrs. Bean came in with a candle.
CHAPTER X.
“You’ll be glad to go to bed, I dare say, my dear,” said the
housekeeper. “If you hear any noises in the night, don’t be afraid;
this old house is full of them. Good-night.”
Freda fled across the hall and hopped up the stairs.
Oh! How long that gallery seemed, skim over the floor as she
might! The candle smoked and flared and guttered in her hand, and
the boards creaked, and the musty smell seemed to choke her. The
row of stately carved oak chairs, ranged along the wall on one side,
seemed to be set ready for the midnight hour when the faded ladies
and the sombre gentlemen should come down from their frames and
hold ghostly converse there. She ran along the stone passage to the
door of her room, and threw it open suddenly.
A man sprang up from his knees before the wide, open grate, in
which a wood fire now burned. The girl, no longer mistress of herself
in her fright and excitement, uttered a cry.
“It’s all right,” said the rough voice which had already begun to
grow familiar to her, “I thought you’d like a fire. So I brought some
sticks, and a log. It’s cold here after France, I expect. Anyhow, the
blaze makes it look more cheerful.”
Freda was touched.
“Oh, thank you—so very much! How kind of you.”
“Stuff! Kind! You’re mistress here now, you know, as you said; and
one must make the mistress comfortable.”
He spoke in a jeering tone, but Freda did not mind that now.
“I wish,” she said, looking wistfully at the blazing log, “that you
were going to stay here, Crispin.”
He gave one of his short, hard laughs.
“I should get spoilt for work,” he said. “You’d make a ladies’-man of
me. Sha’n’t see you again. Good-night.”
Freda held out her hand, and he held it a moment in his, while a
gleam almost of tenderness passed over his seamed and rugged
face. Then he gave her fingers a sudden, rough squeeze, which left
her red girl’s hand for a minute white and helpless.
“Good-night,” he then said again, shortly and as if indifferently. “If I
come into these parts again, I’ll give you a look in.”
He left her hardly time to murmur “good-night” in answer, before
he was out of the room. He put his head in again immediately,
however, to say “Draw the bolt of the door, and you’ll be all right.”
Freda obeyed this direction at once, with another little quiver of the
heart. But Crispin’s kindness had so warmed her that what now
chiefly troubled her was the fact that she would see no more of him
for an indefinite time. The strongest proof of the confidence he had
inspired in her was the fact that she accepted implicitly his
assurance as to her father’s wishes, and resolved to make no
attempt to return to the convent. Indeed, the last three days had
been so full of excitement and adventure that the old, calm years
seemed to have been passed by some other person.
Freda’s last thought as she fell asleep, watching the dancing light
of the fire on the roughly white-washed beams of the ceiling, was,
however, neither of quiet nuns at their prayers in the convent by the
sea, nor of Crispin Bean with his rugged face and hard voice, but of
Oldcastle Farm and one of its occupants.
The girl was tired out; so utterly weary that she was ready to lie
like a log till morning. But presently she began to dream, with the
leaden drowsiness of a person in whom some outward disturbance
struggles with fatigue, of thunder and battling crowds of men. And
then she started into wakefulness, and found that the fire had burnt
low, and that men’s loud voices were disturbing her rest. They
seemed to come, muffled by the massive boards between, from a
chamber under hers; they died away into faintness, and she was so
overpowered with fatigue that she would have dropped to sleep
again almost without troubling herself, when one voice suddenly
broke out above the murmur. It was loud and shrill, and high-pitched,
a voice Freda had never heard before. She could hear the words it
uttered:
“Ye maun stay, ye maun stay. We can’t get on wi’out ye. Do ye
want us to starve?”
And a chorus of evidently assenting murmurs followed. The voices
dropped again, and again the listening girl’s attention relaxed, as
sleep got the better of her senses. But suddenly she was aroused
again, this time by sounds which came from behind the head of the
bed, and were so plain that they seemed to be in the very room.
Sounds as of a man’s footsteps coming up a stone staircase, coming
up unsteadily, with many pauses. Sounds, too, as of heavy weights
being dragged up, and of suppressed laughter and jeers.
“Eh, but tha’s gotten aboot as much as tha’ can carry, eh, Crispin?”
said one voice.
“Tha’ couldn’t climb oop a mast to-night, Crispin,” said another,
during the laughter which succeeded the first speech.
The voice of the man who was on the stairs answered, in low and
husky tones. Although he was the nearest to her, Freda could not
distinguish what he said, except the word “hush.” Then she heard a
mumbling sound, like the drawing back of a sliding door, and then
the dragging of some heavy weight over the boards, and the opening
of a window. Presently the man came back, went down the stone
steps, and re-ascended in the same manner as before. This
happened three or four times, until the voices below died gradually
away, and the sounds ceased. Not until long after all was quiet did
Freda fall asleep again, and for the remainder of the night her rest
was troubled by all sorts of wild dreams.
Next morning, as a consequence of her broken night’s rest, she
did not wake until the housekeeper knocked loudly at the door.
Springing up with a sudden rush of confused memories through her
brain, Freda ran to the door, drew back the bolt, and pulled Mrs.
Bean into the room.
“Oh,” she cried, “this is a dreadful house; how can you stay in it? It
is haunted, or——”
Mrs. Bean interrupted her with a peculiar expression on her face.
“Didn’t I tell you to take no notice of anything you heard?” she
asked quietly. “What does it matter to you what goes on outside your
door, while you’re locked safe inside?”
“But I want to know——” began Freda.
Again Mrs. Bean cut her short.
“Didn’t they teach you, in the place you came from, that curiosity
was the worst sin a woman can have?” she asked drily. “A wise
woman doesn’t meddle with anything outside her own business, and
especially she does not poke her nose into any business where men
only are concerned. I see you’ve had a fire,” she went on in a less
severe tone.
“Yes, Crispin made it for me.”
Mrs. Bean shook her head good-humouredly.
“You’re making a fool of that man. He was to have gone away last
night, and he is still hanging about this morning. And it’s all because
of you, I’m certain. Now make haste and get dressed, for I’ve got a
tiresome day’s work before me, and I want to get the breakfast done
with as soon as I can.”
It was a bright, sunny morning. The numerous windows let in
floods of sunshine, the snow outside dazzled the eyes, even the
knights and dames in the picture-gallery seemed to be in better
spirits. In the dining-room Freda found Crispin, who affected to treat
her with marked coldness, and to be grieved that he had had to put
off his journey until the following night. Now although she stood in
some awe of the housekeeper, Freda had no fear whatever of
Crispin; so she very soon opened the dangerous subject.
“Crispin,” she began solemnly, “I heard you last night after I was in
bed.”
“Very likely,” he answered quietly.
“There were some men with you.”
“Yes, so there were.”
“The voices seemed to come from under my room.”
“So they did.”
“And some one came up the stairs.”
He nodded.
“Dragging a heavy weight over the floor,” continued she. “And then
some one opened a window. And the sounds went on over and over
again.”
“Quite right. Well?”
“What did it all mean?”
“That I had some of the men from your father’s yacht here, and
told them all about his death. I suppose you don’t wish the yacht
sold? It would throw half a dozen men out of work.”
“No-o,” said Freda. “But——”
“Here’s your breakfast,” he interrupted, as Mrs. Bean brought a
laden tray into the room.
CHAPTER XI.
Crispin had breakfasted, but he remained in the room, “to wait,” as
he said with grim jocularity, “on the mistress of the house.”
Whenever she tried to bring the talk again to the subject of the
noises of the night, he slid away from it in a most skilful manner, so
that she could find out nothing from him, and presently got rather a
sharp warning about the value of silence. When she again
expressed a wish to see her father, too, he answered very shortly, so
that she began to understand that Crispin’s goodwill did not render
him pliable. Mrs. Bean was in the room when she made this last
request. She stood up suddenly, with a crumb-brush in her hand,
and a look of great annoyance upon her face.
“There’ll have to be an inquest!” cried she. “Did you ever think of
that?”
And she turned in great agitation to Crispin, who was just lighting
his pipe. He only nodded and said quietly:
“Don’t you trouble yourself. I’ve thought of all that. You just put on
your bonnet and run down to the town, and tell Eliza Poad that the
master’s shot himself. Then it will be all over the county in about
three quarters of an hour, and the police will have notice, and the
coroner will be sent for without any trouble to you. And within two
hours Mr. Staynes will come panting up the hill with religious
consolation.”
“I sha’n’t see him, interfering old nuisance!” said Mrs. Bean
indignantly.
“No, Miss Freda will. And you, Nell, will go to the undertaker’s; go
to John Posgate—we owe him a good turn—and tell him you don’t
want any of his measuring: he’s to send a coffin, largest size he
makes, up to the house-door by to-night, and leave it there. And then
go round to the house of that young doctor that’s just come here (he
lives in one of the little new red houses on the other side of the
bridge past the station) and tell him what has happened. And you will
be glad if he will step up at once. That’s all.”
These details made Freda sick; she retreated, shivering, to the
window, and there she perceived a long, much trampled foot-track in
the snow across the walled-in garden. She noticed it very
particularly, wondering whether it was by this way that the men had
entered the house on the preceding evening. Then, as she was by
this time alone, she went softly out of the room and upstairs, and
turned the handle of the door of her father’s room. It opened. She
saw, with a wildly-beating heart, that the curtains of the bed were
drawn back, and that on it there lay the body of a man.
Suddenly she was lifted off her feet, and carried back from the
door of the room.
“Look here,” said Crispin drily, as he put her down, “haven’t you
learnt by this time that it’s of no more use to try to circumvent me
than to fight the sea? You will see your father when I please and not
before. Now go downstairs and wait till the Vicar comes, and tell the
old fool just as little as you can help, if you don’t want to get yourself
or anybody else into trouble.”
Freda obeyed, mute and ashamed. She crept downstairs, returned
to the dining-room, and fed the hungry birds till the bell sounded.
Running out to the court-yard gate, she drew back the two heavy
bolts which fastened it. Waiting outside were a lady and gentleman
whom she at once guessed to be the Vicar and his wife.
The Reverend Berkley Staynes was generally considered the
greatest “character” in Presterby. A member of one of the county
families, with a fairly good living and a better private income, he was
an autocrat who considered his flock of very small account indeed
compared with the well-being of their pastor. Although close upon
eighty years of age, and quite unable to perform a tithe of his parish
duties, he would never take a curate, partly from motives of
economy, and partly because he feared that an assistant might
introduce some “crank” of week-day services or early Communion,
and wake up some of the parishioners into disconcerting religious
activity. Never at any time over-burdened with brains, he had been at
one time an exceedingly handsome man, athletic and muscular, and
a great encourager of health-giving sports and pastimes. For these
former good qualities, and from a natural, loyal conservatism, the
good Yorkshire folk bore with him, maintained respectful silence
while he droned out his antiquated sermons, and shut their eyes to
his inefficiency. Mrs. Staynes belonged to a type of clergyman’s wife
sufficiently common. She was much younger than her husband, and
slavishly devoted to him, giving him the absurd homage which he
believed to be his due, and working like a nigger to shield his
deficiencies from the public notice.
Something of this was to be guessed even by inexperienced Freda
as she opened the gate to them. A tall, but somewhat bent old
gentleman, still handsome in his age, with silver-white hair and a
good-looking, rather stupid face, dressed well and with scrupulous
neatness, stood before her. Behind him rather than at his side was a
small, middle-aged woman dressed in what looked like a black
pillow-case, a long narrow black cloth jacket and a rusty black hat of
the old mushroom shape. She had a fresh-coloured face and a
simple-minded smile, and she habitually carried her left hand planted
against her waist in a manner which emphasised the undesirable
curves in her “stumpy” figure.
“H’m, a new servant!” said the Reverend Berkley Staynes, looking
searchingly at Freda. “Well, what the Captain wanted more servants
for, considering that he never received anybody or kept the place up,
I’m sure I don’t know! Why don’t you wear a cap, young woman?”
“I’m not a servant,” said Freda. “I’m Captain Mulgrave’s daughter.
Will you please come in?”
She led the way, without waiting for any more comments, across
the court-yard, through the hall, and into the dining-room; and she
noticed as she went how both her visitors peered about them and
walked slowly, as if they had not been inside the house before, and
were curious about it. In the dining-room they sat down, and the
Vicar, glancing round the room inquisitively as he spoke, began a
close interrogatory as to Freda’s history. His wife looked
uncomfortable and he solemn when she mentioned the convent.
“Ah! Bad places, those convents,” he said, shaking his head,
“nests of laziness and superstition.”
“Dear me, yes,” said Mrs. Staynes. “But we’ll cure you of all that.
You shall come to the Sunday school and hear Mr. Staynes talking to
the girls; and when you feel pretty firm in the doctrine, we’ll have you
confirmed.”
“Thank you,” said Freda.
“I’ll come in again myself in a day or two, and perhaps we’ll have
you round to tea. You’d like to come, I daresay.”
“Of course she would,” chimed in Mrs. Staynes.
“Thank you,” said Freda.
“I think,” said the Vicar, rising and moving towards the door, “that
I’ll go upstairs and just look upon the poor Captain’s face again. I feel
it my duty to. I wish I could have felt happier about him, but I’m sorry
to say he was always deaf to the exhortations of religion.”
“I’m afraid you can’t see him,” said Freda, quietly.
She had had particular injunctions on this point from Crispin, who
had foreseen that the Vicar would think it his duty to satisfy his
curiosity. As Mr. Staynes persisted, brushing her angrily out of his
way, Freda followed him upstairs, and had to point out the door of
the death-chamber. The Vicar tried to open it, but it was locked;
Freda let him push and shake in vain.
“Can you open it for me, girl?” he was at last constrained to ask.
“I think I could, but I have been told not to. I am sorry, but I cannot
help you.”
“And pray who is it that has more authority with you than the Vicar
of the parish?” asked Mr. Staynes when, finding indignation and
expostulation useless, he had to accompany her downstairs.
“Crispin Bean,” she answered simply.
“What!” cried the Vicar, almost staggering back. “That drunken
ruffian Bean! A disgrace to the neighbourhood! Why, it was enough
to keep Christian people away from this house that such a scoundrel
was ever allowed about it.”
The implied taunt at her dead father incensed Freda as much as
the accusations against Crispin.
“I suppose,” she said very quietly, “that my father liked scoundrels
better than Christian people. I think I do too.”
The Vicar drew himself up.
In the midst of his anger at being thwarted, the girl’s answer rather
tickled him.
“I shall come and have a talk to you, young woman,” he said more
amiably, “when you’re in a better frame of mind. You’ve had
everything against you, and I make allowance for it.”
Little Mrs. Staynes, who had listened to the latter part of this
conversation in such horror that she had scarcely breath left to play
her usual part of chorus, followed her husband out, pausing as she
did so to say, in a warning voice:
“Oh, dear child, pray to be forgiven for your conduct to-day.”
Freda, who was distressed to the verge of tears by the whole
interview, let them out by the big gate, and returned to the house.
She was almost frightened to find Crispin in the dining-room, in roars
of laughter.
“Well done, little one,” he said, as she came in. “That’s the way to
serve the tract-mongers.”
But Freda was shocked.
“What did you hear? Where were you?” she asked in a whisper.
“I heard everything. Never mind where I was; there’s many a
corner in this house that you will never see.”
But the girl shrank away, ill-pleased at his praise.
When the housekeeper returned, she was accompanied by the
doctor Crispin had sent her for, and he and Mrs. Bean went upstairs
at once. As soon as she heard their footsteps overhead, Freda went
quickly out into the court-yard, through the great gate, and into the
enclosure beyond, waiting for the doctor to come out.
At last the gate opened to let out a youngish-looking man, with a
correct professional air of unimpeachable respectability. Freda
waited until Mrs. Bean had wished him “good-morning,” and shut the
gate; then she quickly overtook him, and greeted him with some
agitation.
“I beg your pardon, sir,” she began modestly; “you have just seen
my father, I believe.”
“Yes, I have seen him, if Captain Mulgrave was your father.”
Freda answered in the affirmative.
“Did you know him?” she then asked.
“I had not that pleasure. You know, Miss Mulgrave, what a
secluded life your father always led. I have not been long in
Presterby, and although of course, I’ve heard a great deal about him,
I never saw him in life.”
“Do you think he shot himself?”
“No, I think not. From the position of the wound I should think it
more likely that somebody else shot him.”
“And where was the wound?”
“In the back.”
There was a pause. Then Freda looked up in the doctor’s face.
“They won’t tell me anything, so I had to ask you. Thank you for
telling me. Good-bye.”
She left the doctor, and went back slowly to the gate. Mrs. Bean,
who answered her summons, looked angry and disconcerted on
learning how she had been employed.
“I think you’d best have followed your own whims and gone back
to the convent,” she said drily, “we don’t want any more questions
than necessary asked here just now. There’ll be quite enough of a
rumpus as it is.”
She turned her back upon Freda pretty sharply, and walked back
to her kitchen with an offended air. The girl, however, was not to be
shaken off.
“Mrs. Bean,” she said, following her, “this doctor never saw my
father while he was alive!”
There was a pause. Mrs. Bean took up a fork and violently stirred
the contents of a saucepan she held.
“Look here, my dear,” she said, “what has put all these silly ideas
into your head? Don’t you know there’s going to be an inquest?”
She went on stirring her saucepan without looking up. Freda
turned to her eagerly.
“And are these inquest-people men who have known him, and
seen him, and talked to him?”
“Why, of course they are. They’ll be tradesmen out of the town,
most of them, who have supplied him with butter and cheese, beef
and candles, for years and years.”
“Oh,” said Freda, evidently much relieved.
“Now then, you’re satisfied, I suppose?” said Mrs. Bean rather
curiously.
“Oh, yes, thank you very much.”
But in the girl’s tone there was still the vestige of a doubt, and she
went out with a thoughtful face.
It was a very curious thing, Freda thought, that the servant
Blewitt’s body should be found shot in the back, and then that her
father should be shot in exactly the same way. She puzzled herself
over this until her brain reeled, and then she unlocked the front door,
and went along the foot-tracks in the snow the whole length of the
garden to the wall at the bottom. Here was a door, which she went
through, and instead of following the little lane which ran to the right,
down towards the town, she still followed the foot-marks over a
couple of meadows straight in front of her until, coming to a stone
wall, she looked over and discovered the road by which she had
come to the Abbey. A great heap of freshly dug up snow stood
almost in the middle of the road, and by the help of a shed on the
right, Freda was able to identify the spot on which the body of the
servant Blewitt had been discovered by Barnabas Ugthorpe.
Freda turned sick with horror. Her mind had jumped, with that
splendid feminine inspiration which acts independently of logic, and
which is as often marvellously right as stupendously wrong, to the
conclusion that the body of Blewitt had been carried into the Abbey.
So certain did she feel of this, that the question she asked herself
was: Why was this done? And not: Was this done at all? She turned
away from the wall, and went back, this time avoiding the foot-track,
which she believed to have been made on a guilty errand. She was
too horror-struck for tears. She gazed upon the beautiful old house,
as she slowly drew near to it again, as she would have done on
some unhallowed tomb. The sun, which had been shining brightly all
the morning, had begun to melt the snow on the flagged roof, so that
patches of moss-grown stone appeared here and there where the
white mass had slid down, partially dissolved by the warm rays. The
main body of the house was Tudor, of warm red brick with gables,
mullioned windows, and stacks of handsome chimneys. But the west
wing the so-called Abbot’s House, was a plain structure of solid grey
stone, with one little scrap of decorated tooth work to bear witness to
its connection with the Abbey.
There were secrets behind warm red bricks and venerable grey
stone that it was better not to think upon. For the awful conviction
was pressing in upon her that if the body of the murdered
manservant had been brought there, it could only be to conceal the
fact of his murder. Unless, then, it was this mysterious father of hers
who had fired the shot, who could it have been?
CHAPTER XII.
The following was the day of the inquest. It was to be held at the
Abbey itself, and Mrs. Bean had swept the drawing-room, and
uncovered the furniture in that dismal and damp apartment, so that
the coroner and jury might hold their deliberation there. Freda, who
followed the housekeeper about like her shadow, without
acknowledging that it was because a horror had grown upon her of
being left alone in that dreary old house, was helping to dust the old-
fashioned ornaments.
“Mrs. Bean,” she said at last, stopping in the act of dusting the
glass shade over an alabaster urn, in order to clap her hands
together to warm them, “aren’t you going to light a fire here?”
“Yes, I will presently,” answered the housekeeper, whose lips and
nose and hands were purple and stiff with cold.
“It will take a long time to warm this great room, won’t it?”
“Oh, the fire will soon burn up when it’s once lighted.”
However, it didn’t get lighted at all until half an hour before the
coroner and jurymen arrived; and when Mrs. Bean did remember it,
she put in the grate a small handful of newspaper and a few damp
sticks which gave forth smoke instead of heat, and after hissing and
spluttering for some minutes, finally gave up the task of burning
altogether.
Freda stood by the kitchen fire, trying to puzzle out the meaning of
these strange actions, while Mrs. Bean went out into the court-yard
at the summons of the gate-bell. When the housekeeper returned,
she met a gaze from the young girl’s eyes which made her feel
uneasy.
“Are they all come?” asked Freda.
“Yes, the coroner and all of them. They’re in the drawing-room
now.”
“What are they doing now?”
“First, the coroner will charge them; then the witnesses will be
examined——”
“What witnesses?” asked Freda quickly.
“Why, Crispin and I.”
“Crispin will be examined?”
“Yes,” said Nell sharply, “and so will you, if you don’t keep out of
the way. You’d better go upstairs to your room till they’re out of the
house. They won’t be more than an hour, I should think, at the
outside. I’ll come up and tell you when they’re gone.”
So the girl went slowly out of the room, and across the hall, where
she could hear the deliberate tones of the coroner charging the jury,
and upstairs. But on the landing she stopped, and peeping about to
see that she was not watched, she tried the door of her father’s
room, found that it was locked, and dropping softly on her knees,
looked through the key-hole. The bed was opposite to the door.
The body was no longer there.
Freda sprang up from her knees with a white face, ran through the
picture-gallery, and shut herself up in her own room. She knew very
well that a dead body was not easily moved; half-an-hour ago she
had seen it lying on the bed; Mrs. Bean had not been upstairs since;
if Crispin was about the house still, could he move such a weight by
himself, and carry it down the stairs and out of the house without her
having heard or seen him? She sat on a chair near her window, with
her head between her hands, trying to puzzle out the meaning of
these strange occurrences, until the thought came into her mind that
she might perhaps be able, by secreting herself somewhere on the
landing outside her father’s room, to see the jurymen come up on
their investigations, and to hear what they said. So she came softly
out of the room, and through the picture-gallery, and out on to the
wide landing.
The most desolate spot in the whole house this had always
appeared to Freda. As large as a good-sized room, panelled from
oaken floor to moulded ceiling with a raised recess by the mullioned
window, this might have been made a comfortable as well as
handsome corner, while now it was left to the dust and the rats. So
thick was the dust on the boards that two paths might be traced in it,
the one leading to Captain Mulgrave’s room, the other to the door of
the picture-gallery. Except on these two tracks the dust lay thick,
showing the state of neglect into which the old house had fallen.

Full Chapter Viva and Osce Exams in Ophthalmology A Revision Study Guide Timothy H M Fung PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Chapter Viva and Osce Exams in Ophthalmology A Revision Study Guide Timothy H M Fung PDF

Uploaded by

Copyright:

Available Formats

Viva and OSCE Exams in

Ophthalmology A Revision Study Guide

PHR and SPHR Professional in Human Resources

Water operator certification study guide a guide to

OSCEs for the MRCS Part B: A Bailey & Love Revision

The Definitive Guide to the OSCE: The Objective

RHCSA RHCE Red Hat Linux certification study guide

Geography for the IB Diploma Study and Revision Guide

Memorizing Medicine: A Revision Guide 2nd Edition Paul

Questions and Answers in Pain Medicine: A Guide to

Viva and OSCE Exams

Royal Derby Hospital University of Nottingham

ISBN 978-3-030-43062-7 ISBN 978-3-030-43063-4 (eBook)

Nottingham, UK Timothy H. M. Fung

Part I Structured VIVA

1 VIVA Technique: Do’s and Don’ts�������������������������������������������������� 3

2.5 Computerised Tomography (CT)���������������������������������������������� 27

2.13 Electrodiagnostic Tests ������������������������������������������������������������ 55

3.5.7 RCOphth RVO Guidelines 2015

3.18.4 Examination������������������������������������������������������������������ 113

3.26 Acanthamoeba Keratitis������������������������������������������������������������ 128

3.34.4 Immediate Measures ���������������������������������������������������� 137

3.42.3 Methods of Treatment�������������������������������������������������� 148

3.49.6 BSPAR and the RCOphth Guidelines for

4.17 The RCOphth Ophthalmology Service Guidance on

5.7 Public Health England NHS Diabetic Eye Screening

5.15 The RCOphth Ophthalmic Services Guidance on the

Part II Objective Structured Clinical Examination (OSCE)

7 Objective Structured Clinical Examination (OSCE)

8 Anterior Segment ���������������������������������������������������������������������������� 239

8.10.4 Treatment���������������������������������������������������������������������� 246

8.19.2 History�������������������������������������������������������������������������� 256

8.26 Anterior Scleritis���������������������������������������������������������������������� 266

9.5.2 Mechanism of IOP Elevation in Aphakia �������������������� 275

9.15.4 Investigations���������������������������������������������������������������� 287

9.25 Melanocytic Naevus������������������������������������������������������������������ 297

10.7.6 Defining Risk for the Development of

10.14.3 Investigations������������������������������������������������������������ 323

10.24 Multifocal Choroiditis and Panuveitis (MFC) ���������������������� 331

11.7 Restrictive Myopathy in TED ������������������������������������������������ 348

You might also like

Nottingham, UK Timothy H. M. Fung

Part I Structured VIVA

1 VIVA Technique: Do’s and Don’ts�� 3

2.5 Computerised Tomography (CT)�� 27

2.13 Electrodiagnostic Tests �� 55

3.5.7 RCOphth RVO Guidelines 2015

3.18.4 Examination�� 113

3.26 Acanthamoeba Keratitis�� 128

3.34.4 Immediate Measures �� 137

3.42.3 Methods of Treatment�� 148

3.49.6 BSPAR and the RCOphth Guidelines for

4.17 The RCOphth Ophthalmology Service Guidance on

5.7 Public Health England NHS Diabetic Eye Screening

5.15 The RCOphth Ophthalmic Services Guidance on the

Part II Objective Structured Clinical Examination (OSCE)

7 Objective Structured Clinical Examination (OSCE)

8 Anterior Segment �� 239

8.10.4 Treatment�� 246

8.19.2 History�� 256

8.26 Anterior Scleritis�� 266

9.5.2 Mechanism of IOP Elevation in Aphakia �� 275

9.15.4 Investigations�� 287

9.25 Melanocytic Naevus�� 297

10.7.6 Defining Risk for the Development of

10.14.3 Investigations�� 323

10.24 Multifocal Choroiditis and Panuveitis (MFC) �� 331

11.7 Restrictive Myopathy in TED �� 348