A 1 year old girl is brought into your Emergency Department with a swollen eye. The mother reports that she woke up with the eye swollen like that. She was playing happily outside yesterday, and was irritable when she awoke this morning.

1. Outline your differential diagnosis for this child. (30%)

2. List the key features in the history and examination that will clarify your diagnosis. (70%)

1) You are the consultant of a rural emergency department, 500 km away from the nearest ophthalmology unit. A 25 year old man presents with a dart embedded in his right eye after an assault. Outline your management.

2003.1 VAQ 6

A 19 year old female presents with a painful right eye and decreased vision after being out for most of the night previously at clubs. She is normally myopic. Her visual acuity is 6/24 in her right eye and 6/12 in her left eye. A photograph of the eye is shown.

Questiona. Describe the features and list your differential diagnosis. (50%)

b. Outline your further assessment. (50%)

FACEM VAQ Exam 2003.1 – Question 6 Overall pass rate for this question was 61 / 83 (73.5%). This was thought to be a good question overall that had a number of levels

enabling better candidates to do very well. Failures were due to a combination of limited differentials for corneal haziness

combined with limited assessment that followed from this.

2003.2 VAQ 6

A 26 year old man presents to the ED having been hit in the right eye with a wooden block thrown by his young child.

Questiona. Describe the photograph. (50%)b. What are the potential complications of this injury? (50%)

FACEM VAQ Exam 2003.2 – Question 6 Overall pass rate for this question was 29 / 82 (35.4%). A photograph showing a subconjunctival haemorrhage and hyphaema, with an

irregular pupil is shown. Examiners were very disappointed in the standard of answers to this question

particularly as the key information in the stem guided the candidates towards the likely diagnoses.

They were concerned that answers also focused on injuries that were not consistent with the stated mechanism such as head injury, cervical spine trauma and skull fractures.

Such answers were specifically penalized as they showed lack of perspective and a tendency towards formulaic rather than considered answers.

Since the question specifically asked for complications related to this injury they were at a loss to explain why answers focused on issues other than the eye.

2005.2 VAQ 8

A 65 year old man presents with painless loss of vision in his left eye. His fundoscopic examination is shown.

Questiona. Describe and interpret his fundoscopic examination. (50%)

b. What are the underlying causes of this condition? (50%)

FACEM VAQ Exam 20095.2 – Question 8 Overall pass rate for this question was 48/56 (85.7%). The image of the retina suggests retinal vein occlusion The examiners expected that candidates would highlight in their description

the features of central retinal vein occlusion seen in the image such as venous tortuosity and retinal haemorrhages

The second part of the answer needed to make clear that this was an atherosclerotic/clotting process (and not an embolic one) and as such the causes were the systemic causes of these processes.

Failing answers did not identify this as a central retinal vein occlusion or incorrectly described it as an embolic phenomenon.

2006.1 VAQ 4

This 30 year old man was assaulted with a broom stick.

Questiona. Describe and interpret this man’s

photograph.(100%)

FACEM VAQ Exam 2006.1 – Question 4 Overall pass rate for this question was 29/40 (72.5%) A clinical photograph suggests conjunctival, corneal and anterior chamber

injury The examiners expected that a clear description as above would include a clear

statement that this injury is sight threatening. The interpretation needed to include a differential diagnosis including a

penetrating eye injury or ruptured globe. Failing answers did not offer such an interpretation.

2007.2 VAQ 5

A 7 year old boy is brought to your emergency department by his teacher after sustaining an injury to his left eye during sport at school that morning.

Questiona. Describe and interpret his photograph. (30%)b. Outline your assessment. (70%)

FACEM VAQ Exam 2007.2 – Question 5 The overall pass rate for this question was 50/77 (64.9%). Photograph showed a child with a hyphaema with a swollen, ptosed upper

eyelid and some minor grazes in the infraorbital region. The examiners agreed that this was a good image raising core issues for

discussion. Satisfactory answers identified the image abnormalities and addressed a focused history, physical examination and relevant tests such as use of slit lamp.

Failed answers missed the hyphaema or failed to make a suitable assessment.

Of note was that both examiners expressed concern that assessment did not include mention of past health, medications and allergies or assessment for injuries in other body areas.

The question may have benefited from a more specific scenario excluding previous illness and other injuries at presentation.

Question three – Photograph

A twenty one year old workman presents after industrial strength ammonia splashed into his left eye.

a) Describe and interpret his photo. (30%) b) Outline your immediate management. (70%)

a) Photograph of left eye – in upward gaze, upper half cornea and globe not visualised

Large area medial and inferior to cornea (6-9 o’clock) of marked pallor c/w ischaemia

Generalised conjunctival hyperemia c/w injury ? slough medial canthus area and adjacent conjunctiva and lid margin

epithelial defect cornea 7-9 o’clock pupil not fully visualised cornea not fully visualised (eg check for opacification)

Summary: Injury c/w severe alkaline injury (ammonia) including conjunctival ischaemia – need full ophthalmological assessment as at risk of penetrating injury including to anterior and posterior eye.

b) Management of severe ocular alkali injury / globe at risk and potentially vision thtreatening

Immediate first aid as priority Copious irrigation with NS

o at least 1-2 L (30 minutes) minimumo guided by pH testing (aim pH < 7.4)o Include irrigation under both lids (eversion of both lids) o check fornices and include sweep under lid to remove

particulate mattero lids may be retracted manually with a retractor, lid speculum,

or bent paperclip.o Morgan lens may facilitate irrigation

Analgesiao topical anaesthetic drops, repeat as needed, will be required to facilitate

irrigation, eg amethocaine 0.5% 1-2 dropso plus oral analgesia (eg combination) +/- titrated parenteral narcotic

Tetanus as required Communication to patient / family Consultation (may advise topical Rx) / Disposition - Ophthalmological

consultation – same day assessment. Note severe injury will require hospitalisation under specialist ophthalmology unit. (Anticipate need for cycloplegics, topical steroids, oral Vitamin C , IO pressure monitoring and management)