Objectively Structured Clinical Examination (OSCE) in Ophthalmology Amar Agarwal, Athiya Agarwal, Sunita Agarwal, DP Prakash
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1Objectively Structured Clinical Examination (OSCE) in Ophthalmology2
3Objectively Structured Clinical Examination (OSCE) in Ophthalmology
Amar Agarwal MS FRCS FRCOPHTH DP Prakash FRCS DNB OPHTHA DO Sunita Agarwal MS Athiya Agarwal MD DO Dr. Agarwal's Group of Eye Hospitals and Eye Research Centre 19 Cathedral Road, Chennai- 600 086, India
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Objectively Structured Clinical Examination (OSCE) in Ophthalmology
© 2005, Amar Agarwal, DP Prakash, Sunita Agarwal, Athiya Agarwal
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 2005
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
This book is dedicated to A great friend and surgeon
Dr Roberto Pinelli,
The evaluation techniques have been put to a critical scrutiny for a long time. Clinical assessments apart from being a long and tiring process leave transparency and bias factor a point of discussion. Short and multiple choice question formats have reduced the bias and increased transparency to a great extent in testing the cognitive skills. Objectively structured clinical examination (OSCE) has been visualised as clinical evaluation techniques to eliminate the ambiguity and bias in the clinical examination.
This book is the first attempt to prepare a sample module to introduce OSCE to the students of Ophthalmology. The book has good illustrations along the discrete questions framed to reach with their clear reply. The book has a good learning material as well as clear and critical analysis of the content there in.
I am sure that this book will justify its publication and help to promote OSCE as a friendly induction of a good evaluation technique.
DK Mehta
Director, Guru Nanak Eye Centre
Director, Professor Ophthalmology
Maulana Azad Medical College
New Delhi, India
Including OSCE (Objectively Structured Clinical Examination) into the DNB examination is an applaudable decision as it enhances the quality of the examinations and evaluates the performance of the students in a very practical and unbiased manner.
On the other hand, students are not trained for this kind of examination and there is an acute need for more literature on the type of questions asked and appropriate responses. This book seeks to equip the students with a suitable knowledge of the system and to enhance their performance in the examination.
The first of its kind, this book will prove invaluable to all the postgraduate students whether Primary DNB, DO or MS. It will also make interesting reading for examiners.
It is a pleasure to present to you this indispensable guide to the OSCE.
Amar Agarwal
DP Prakash
Sunita Agarwal
Athiya Agarwal
13About the OSCE Pattern for DNB Ophthalmology  
OSCE stands for objectively structured clinical examination. The National Board of Examinations (NBE) has introduced this new pattern for the DNB (Diplomate National Board) final clinical examination since 2003. The main purpose of this new pattern is to examine all the candidates with the same set of questions even for the clinical exams thereby eliminating any bias that may occur with different set of questions at different centers. The examination starts at the same time at all the centers all over India and the students answer the same set of 25 to 30 questions. Each question is kept in a station or cabin and the student enters the cabin at the ring of a buzzer. The student gets 5 minutes to read the question and write the answers for the same. At the end of 5 minutes the buzzer rings and the student is supposed to hand over the answer for that question to the examiner. Then he moves to the next station where another set of questions await him which he answers in 5 minutes. The examination hall is divided into 30 stations and each student occupies 1 station at the start of the examination. At the end of 5 minutes the student moves on to the next station which was occupied by another student who also moves on. Thus, all the students get the same set of questions and the same time of 5 minutes for answering each question. By this process objectivity is established in the examination. The student has to be alert and stick to the time limit as he cannot make up for lost time.
The questions for this OSCE pattern are designed in such a way, to examine the student's depth and breadth of knowledge in various sub-specialties of ophthalmology. The questions fall under the following sub-heads, namely:
  1. Observation stations.
  2. Slit lamp photographs.
  3. Fundus photographs and flourescein angiograms.
  4. Clinical photographs of squint patients in diagnostic positions of gaze.
  5. Clinical investigation reports.
  6. Video of surgical procedures.
  7. Electro-diagnostic procedure reports.
  8. Radiology.
  9. Microbiology slides and specimen.
  10. Pathology slides and specimen.
  11. Refraction techniques.14
  12. Recent advances in ophthalmology, and
  13. Community ophthalmology.
In this section the student is asked to perform a clinical examination technique like slit lamp examination or retinoscopy in front of an observer examiner. The observer examiner will mark the student in 5 minutes according to the key given to him. For example: if the question is perform retinoscopy on the patient dilated with cyclopentolate the marks are distributed in the following manner:
  1. First look for cycloplegia by checking the pupil for light and accommodation—1 mark
  2. Wear the trial frame on the patient—½ mark
  3. Choose your working distance either ½ meter or 2/3 meter and stick to it till the end of the examination—½ mark
  4. Place the thumb on the slit rotator of the retinoscope and check the movement in the horizontal and vertical meridians—1 mark
  5. Choose lenses systematically and replace the lenses in the trial set—1 mark
  6. Write the retinoscopy value as a power cross mentioning the working distance—1 mark.
From the above it is evident that the student is evaluated on his technique rather than on the result of the test. Hence, it is important that the student routinely practice all the observation station questions given in this book carefully before the examination.
Anterior segment photographs may be displayed and questions will be asked. It is better to first read the question then look at the photograph and then once again read the question before answering. This is because the questions may sometimes carry a clue which might be helpful for answering. Try to keep the answer to the point and be clear. The student has only 5 minutes to answer and move to the next station.
Look at many fundus photographs and fluorescein angiograms of especially diabetic retinopathy cases. Be sure about classification of retinopathy based on ETDRS and similarly for ROP.15
The student will most likely be shown photographs of squint patients in all 9 diagnostic positions. Read the photograph carefully and systematically from the primary position then proceeding to the versions and finally the elevation and depression. Formulate the diagnosis based on the photograph and any clue that may have been given in the question in the form of history.
The student may be shown a video of surgical procedures like phaconit, phacotrab, penetrating keratoplasty with IOL, viscocanalostomy or lasik laser. It is advisable to first read the questions and then see the video to look for answers. This section will have the latest surgical procedures and the student is advised to be abreast with recent trends.
Electroretinogram, VEP, EOG, orbscan, aberrometry, field test reports, Amsler charts and any other diagnostic report may be shown and questions asked on it. The student has to familiarize himself with the results, their limitations, etc.
CT scans, MRI scans, ultrasonography pictures, X-rays or any other procedure like dacryocystography may be shown and questions based on that. The student should be familiar with the method employed to take the scan for example: whether it's a T1 or T2 weighted image in MRI scanning.
Procedure of Gram's staining and KOH mount are important. Look at the question first before looking at the slide as the question might carry a clue as to which structure is mounted.
The student may be asked about the National Blindness Control Programme or about any nationwide programme like, vit-A supplementation or eye banking.
In the OSCE pattern the student will be tested in all branches of ophthalmology without bias and objectively. The student should prepare for the OSCE exams 16in a systematic manner to come out successful. The total marks allotted for the OSCE exams is 150 and it is theoretically-possible to score full marks. As of now there is no negative marking in the OSCE examinations and hence the student is advised to attempt all questions. A student by and large will have to pass the OSCE test to pass the total clinical examination.