Objective structured practical question (ospe)

Objective Structured Practical
Question (OSPE)
Subject: Ophthalmology
According to the course curriculum
of Post graduate ophthalmology
7/17/2014 1anjumk38dmc@gmail.com

AUTHOR:
Dr Md Anisur Rahman Anjum.
MBBS (Dhaka Medical College). DO (Dhaka
University) FCPS (EYE)
Associate Professor
National Institute of Ophthalmology
Dhaka, Bangladesh.
Chamber: Mojibunnessa Eye Hospital
House: 18 Road: 6. Dhanmondi, Dhaka, 1205.
Bangladesh.
Email: anjumk38dmc@gmail.com
Cell: 01711-832397

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Question
• Your patient needs +2.00 D to see distance clearly.
However, he can tolerate up to +4.00D without
getting blurred distance vision. His cycloplegic
refraction is +6.00D sphere. What are the values in
diopter of his?
1) Absolute hypermetropia?
2) Manifest hypermetropia?
3) Facultative hypermetropia?
4) Latent hypermetropia?

Answer
1) Absolute hypermetropia = + 2.00D
(absolute hypermetropia is defined as the least
amount of plus lenses needed for clear vision without
cycloplegia)
2) Manifest hypermetropia = + 4.00D
(manifest hypermetropia is defined as without
cylcoplegia, the most plus correction that can be
tolerated without blurring of vision)

Answer (Contd)
3) Facultative hypermetropia = + 2.00D
(facultative hypermetropia is defined as the
difference between absolute and manifest
hypermetropia + 4.00D - + 2.00D = + 2.00 D)
4) Latent hypermetropia = + 2.00 D
(latent hypermetropia is defined as the difference
between manifest hypermetropia and hypermetropia
measured with cycloplegia + 6.00D - + 4.00D = +
2.00D)

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Question
• The following patients have 6/6 vision (with spectacle
correction where needed) and have no cataract. The results
of the refraction and keratometry are as shown below:
• Patient A: Refraction: OD -2.50D OS plano
• Average Keratometry: OD 44.50D OS 44.50D
• Patient B: Refraction: OD -2.50D OS plano
• Average Keratometry: OD 44.50D OS 42.00D
• a. What types of myopia does i) patient A and ii) patient B
have?
• b. Which patient is likely to get aniseikonia if the myopia
were corrected with glasses?

ANSWER
ANS=1) Patient a axial myopia. Pt b.
refractive myopia. 3+3=6
ANS= 2) Patient B. The use of glass in
refractive myopia is associated with
diminution of image. Whereas in axial myopia
as in patient A the size of the image is not
altered.=4

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A stenopaic slit showed is used to test the eye of a patient with
astigmatism.
 When the slit is held at position
like above fig, the patient
requires a +3.00D sphere to see
clearly and when the slit is held
at position like below fig, the
patient requires a +2.00D
sphere to see clearly.
• a. Draw the power cross for this
patient.
• b. What is the prescription
needed to correct this patient's
vision.

ANSWER
• Ans b
• +3.00/-1.00 Dcyl 90
• OR
• +2.00/+1.00 Dcyl 180

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Question
• A 40 year-old myopic woman is recently prescribed
soft contact lenses for the first time. She returned two
weeks later and complains that her reading vision
is not as good as with her glasses. Retest shows her
visual acuity to be 6/6 in both eyes with the contact
lenses and the lenses were of the right prescription
and well-fitted. Why does she have problem reading
with her contact lenses but not with her glasses?

Answer
• The patient is pre-presbyopic. Myopes require
less accommodation with glasses than contact
lenses. In addition, the prismatic effect (base-
in prism) offered by the concave glasses assist
convergence during reading.

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Question
A patient comes for refractive surgery with
keratometry readings of 43.0 D/42.0 D and a
manifest refraction of -9.5 D. If LASIK were
performed, what would be the postoperative
average keratometry reading?

Answer
The formula is keratometry change = (0.8 X
refractive change).
Here, the keratometry change = 0.8 x 9.5 D = 7.6
so the calculated final postoperative average is
K = {(43.0 D + 42 .0 D)÷2 }- 7.6 D = 34.9 D.

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Question
• Referring to the LogMAR visual acuity chart.
1) What does LogMAR stand for?
2) What is the distance between the two letters in each
row?
3) What is the distance between adjacent rows of
letters?
4) What is the LogMAR value for a visual acuity of:
• i. 6/60 and
ii. 6/6?

Answer
1) Logarithm of the Minimal Angle of Resolution.
It is also called the Bailey-Lovie chart.
2) The distance between the letters in each row is equal
to one letter width of the same row.
3) The distance between adjacent row is equal to the
height of the letters in the smaller row i.e the letters
below.
4) 1.0 for 6/60 and 0 for 6/6.

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QUESTION
A patient has a visual acuity of 6/6 in both eyes while
wearing glasses with the following prescriptions:
• OD -1.00/-0.50 X 90
OS -2.25 / -1.75 X 180
• The keratometry reveals the following results:
• OD 7.85 mm along 1800 (43.00D)
7.85 mm along 900 (43.00D)
• OS 7.80 mm along 1800 (43.25D)
7.50 mm along 900 (45.00D)

QUESTION
1. Which structure contributes to the
astigmatism in the
a. right eye? = 3
b. left eye? = 3
 2. If the patient were to wear spherical hard
contact lenses, which eye will see better? =4

ANSWER
• 1a) the lens
• 1b) the cornea.
• 2) The left eye

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Question
• A patient with bilateral anterior and intermediate
uveitis is suspected of having sarcoidosis. There are
no conjunctival or eyelid granuloma. Chest x- ray
shows no abnormalities. serum angiotensin-
converting enzyme (ACE) level is normal.
1) Which investigation will confirm the diagnosis?
2) Which is the best single screening test for
sarcoidosis?
3) What is the characteristic of Heerfordt syndrome
(uveoparotid fever)?

Answer
1) High-resolution computed tomographic scan of
the chest.
2) X-Ray chest.
3) Heerfordt syndrome (uveoparotid fever),is
characterized by
uveitis,
parotitis,
fever, and
facial nerve palsy

Explanation
• The definitive diagnosis of sarcoidosis relies on histologic
confirmation of noncaseating granulomata. A chest
radiograph is probably the best single screening test for
sarcoidosis, as it reveals abnormal results in approximately
90% of the patients with active Disease. Thin-cut spiral
computed tomographic( CT) imaging is a more sensitive
imaging modality and may be particularly valuable in the
patient with a normal-appearing chest radiograph in whom
there remains a high clinical suspicion for disease. In such
cases, parenchymal, mediastinal, and hilar structures with
distinctive CT patterns highly suggestive for sarcoidosis
may lead to the diagnosis. Although serum ACE and
lysozyme levels may be abnormally elevated neither is
diagnostic nor specific.

• Source: AAO Volume=9. Page= 171-177.

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Question
A 40 – year old lady presented with severe
headache, examination revels 6/6 vision both
eyes with papilloedema.
1) What are the investigations you have to do to
diagnosed the patient.
2) What are the MRI findings of pseudotumor
cerebri and ICSOL?
3) Mention the CSF findings of PTC?

Answer
• 1)
i. MRI/CT brain
ii. LP CSF findings
iii. RBS/FBS & 2 hrs after breakfast
iv. Measure BP

Answer
 2.
i. PTC → Normal/ slit like ventricle.
ii. ICSOL → Definite mass. Ventricular
enlargement.
 3
CSF pressure raised.

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Scenario
• A lady at childbearing age (overweight) came to
you with the complaints of Headache, Dizziness,
nausea, and vomiting but typically there are no
alterations of consciousness or higher cognitive
function. Tinnitus, or a "rushing" sound in the
ears, transient visual obscurations, general
blurriness, and intermittent horizontal diplopia.
These symptoms tend to worsen in association
with Valsalva maneuvers and changes in posture.
Reports of ocular pain, particularly with extreme
eye movements, have also been noted.

Question
i. What is your diagnosis? === 1
ii. What are the other D/D? write 2 === 2
iii. What will you get in fundsoscopic
examination? Write 3 ========== 3
iv. What will be the most common field defect?
==================== 1
v. Write 3 criteria.============== 3

Answer
i. Pseudotumor cerebri
ii. a)Migraine, b) intracranial tumor.
iii. a) bilaterally swollen, edematous optic nerves
consistent with true papilledema. b) striations
within the nerve fiber layer, c) blurring of the
superior and inferior margins of the neural
rim, d) Chronic papilledema may result in
atrophy of the nerve head,

Answer
4) enlarged blind spot, ( followed by a nasal
deficit, typically affecting the inferior
quadrants. Other field losses seen in PTC
include arcuate defects, nasal step, generalized
constriction, and least commonly, cecocentral
scotoma.)

Answer
5) Pseudotumor cerebri is a syndrome disorder
defined clinically by four criteria:
(1) elevated intracranial pressure as demonstrated by
lumbar puncture;
(2) normal cerebral anatomy, as demonstrated by
neuroradiographic evaluation;
(3) normal cerebrospinal fluid composition; and
(4) signs and symptoms of increased intracranial
pressure, including papilledema.

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Question
• A new born baby came to you with Central
corneal opacity present at birth, iridocorneal
adhesions, cataract, elevated lOP, and cardiac
abnormalities.
1) What may be the possible diagnosis?
2) What are the D/D?
3) Is the condition usually bilateral or unilateral?

Answer
1) . Peters anomaly
2) .
i. congenital hereditary endothelial dystrophy
(CHED)
ii. congenital glaucoma
iii. Peters plus.
3) About 80% of the case is bilateral.

Explanation
Peters plus refers to the same finding associated with
limb dwarfism. CHED does not have elevated lOP.
Corneal opacity and iridocorneal adhesions are not
consistent with congenital glaucoma alone

• Peter’s anomaly is a central corneal opacity present at
birth that may be associated with variable degrees of
iridocorneal adhesion extending from the region of the
iris collarette to the border of the opacity.
Approximately 80% of cases are bilateral. Associated
ocular abnormalities are present in approximately
50% of cases. Ocular abnormalities include
keratolenticular touch, cataract, congenital
glaucoma, microcornea, aniridia. Characteristic
histopathologic findings in Peter’s anomaly include a
localized absence of the corneal endothelium and
Descemet's membrane beneath the area of opacity.

• Peter’s anomaly has been associated with systemic
malformations in up to 60% of patients. These abnormalities
include developmental delay, heart defects, external ear
abnormalities, hearing loss, CNS deficits, spinal defects,
gastrointestinal and genitourinary defects, facial clefts, and
skeletal anomalies. Although systemic malformations may be
associated with genetically transmitted syndromes (trisomy
13- 5, Peters-plus syndrome, Kivlin syndrome, Pfeiffer
syndrome), these associations are the exception rather than the
rule.
• Most cases of Peter’s anomaly occur sporadically; however,
both autosomal recessive and dominant modes of
inheritance have been reported.

• Source: AAO Volume=8. Page 256, 257,
258, 261

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Question
• A Patient complaints of bilateral floaters,
distortion of central vision, which is wax and
wane over many months. The external eye is often
white and uninflamed.
1) What is your diagnosis?
2) What are the systemic diseases be associated?
3) What findings will you get?
4) What ocular investigation will you do?
5) What are the causes of vision loss?

Answer
• 1) Intermediate uveitis/Pars planitis.
• 2)
i. MS
ii. Sarcoidosis.
3)
i. Vitreous cells
ii. Vitreous snow ball
iii. Vitreous snow banking

Answer
4)
i. FA
ii. OCT
5)
i. Chronic CME
ii. Macular hole formation

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Question
• A 25 years lady came to you with the complaints of
transient visual obscurations last only a few seconds
and are characterized by a ‘greying out’ or
‘darkening’ of vision in one or both eyes, often
precipitated by changes in posture.
2) Write 2 D/D.
3) Write 2 investigations.

Answer
1) Papilloedema.
2)
i. Anterior ischaemic optic neuropathy in
patients with giant cell arteritis.
ii. Migraine.
3)
i. MRI
ii. Superficial temporal artery biopsy

• Source: Jack, J, Kanski chapter: 19
Neuro-ophthalmology (migraine)

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Question
 You received a call from obstetrics emergency ward
to see a hypertensive 40 yrs old lady carrying for 7
months who gave history of repeated convulsions
followed by loss of vision. You found VA –PL in B/E,
Fundus & pupil reactions are normal in B/E.
1) -What is the possibility?
2) -What might be the underlying causes?
3) -What investigations you suggests?

Answer
1) Possibility
i. —Cortical blindness
2) Causes
i. Eclampsia leading to occipital infraction.
ii. Hypertensive aneurismal rupture leading to
occipital haemorrhage

Answer
3) The investigations:
I. -CT scan of brain---for haemorrhage
II. -MRI of brain--------for infraction
III. -Urinary protein------for eclampsia
IV.-Total platelet count and or FDP( fibrin
degradation product)------------for DIC
(platelet count will decrease & FDP will
increase)

Explanation
• Explanation---The lady has eclampsic attack
leading to DIC (dessiminated intravascular
coagulation)or hypertensive aneurismal
rupture causing occipital infraction or
haemorrhage respectively.

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Question
• Q-4 A middle aged female referred to neuro
ophthalmology clinic by an ophthalmologist who noted
mild papilloedema both eye with recent onset of severe
headache which was not relieved by any analgesics and
a month of treatment with adequate Acemox tablets ,
repeated lumber puncture prior to which CT scan and
MRI revealed nothing except ventriculomegaly ( gave
no impression of ICSOL or Duct stenosis)
1) What might be the possibilities? Mention 2
2) What else investigations do you want to do?-------4
3) What may be the treatment?--------2

Answer
1) Possibilities are-
i. Cerebral venous sinus thrombosis
ii. Obstructive hydrocephalus following TB
meningitis
2) Other Investigations
i. MRV
ii. CSF study
iii. MT test
iv. CBC with ESR

Answer
3) Treatment----
i. Refer to Neurologist.
ii. Heparin or Warferrin therapy.
iii. Anti TB drug 9 m regimen with steroid,
sometimes shunt surgery may be required in
difficult cases.

Explanation:
• Explanation: The clinical features mimics this is a case of
Idiopathic Intracranial HTN but it denies when not
responding to any of its treatments. Again it denies ICSOL
or Acueduct stenosis since CT scan and MRI revealed
nothing except ventriculomegaly, incase of IIH the
ventricles become slit like but never dilated . The dilemma
in diagnosis of such cases of middle aged women with
nonresponding headache commonly present with cerebral
venous sinus thrombosis which is confirmed by
MRV(magnetic resonance venogram) that shows
segmentation of blood column in cerebral sinuses. The treat
is by Low molecular weight heparin or warferrin. Another
possibility in the context of our country is obstructive
hydrocephalus following TB meningitis.

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Scenario & Question
12 year-old boy whose parents are seeking a second
opinion for his poor vision in the right eye noted 3
years ago. He has been followed up by an
ophthalmologist who initially started him on a course
of antibiotics presuming it was toxoplasmosis.
..
On Examination:
 VAR 6/18. VAL=6/6p
 Ocular Motility= Full in all gaze.
 No RAPD
 IOP 12 mmHg OD/ 13 mmHg OS

Fundus R/E. Fundus=L/E

FA

Question
1) What your diagnosis? = 2
2) What is the prognosis.=3
3) How vision deteriorate? Mention two causes.=5

Answer
1) Best (vitelliform) macular dystrophy.
2) Five stages
 Pre-vitelliform
 Vitelliform
 Pseudohypopyon
 Vitelliruptive
 Atrophic

Answer
• 3) Prognosis is reasonably good until the 5th decade
after which visual acuity declines in one or both eyes.
• 4) Any two
• SRNVM,
• Scarring.
• geographic atrophy

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This 30 year-old HIV
positive man was referred by
his physician because of this
appearance in the left retina.
He has no history of diabetes
mellitus or hypertension.

Question
1) What is the main differential diagnosis?
2) Which HIV patient is at risk of developing
this condition?
3) How would differentiate the conditions
mentioned in a.?
4) What other conditions can give rise to the
above fundal appearance?

Answer
1) The picture shows a whitish lesion. The main
differential diagnosis, given the history, is
between HIV retinopathy and
cytomegalovirus (CMV) retinopathy.
2) Depleted CD4+ lymphocyte count is the most
common risk factor for developing ocular
manifestation of AIDS. The incidence with
decreased CD4+ counts.

Answer
3) HIV retinopathy is usually multifocal, posterior to the
equator and less than one disc diameter. The patient
has no visual complaints and the lesions may fade
after several weeks. The white lesion in HIV
retinopathy is caused by microvasculopathy (cotton-
wool spots). The vasculopathy may be caused by
occlusion due to deposition of the immune-complex
or abnormal endothelial cells.

Answer
In contrast patient with CMV retinopathy
tends to complain of floaters and the lesion
progresses rapidly without treatment causing
retinal haemorrhages and necrosis.
Suspicious lesions should be observed over a
few weeks to document any enlargement.

Answer
 4) The following conditions may give rise to a whitish retinal
lesion or cotton wool spots:
 diabetes mellitus
 Hypertension
 collagen vascular diseases such as SLE
 retinal vein occlusion
 retinal artery occlusion
 chest trauma in Purtscher's retinopathy
 Anaemia
 leukaemia

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Color fundus photograph shows inferotemporal retinal vein
occlusion, retinal periphlebitis and macular edema

Question
• A man of 25 year old (normotensive, non diabetic, non
smoker & non alcoholic) came to you with the complaints
of sudden loss of vision. He has also given history of
repeated attacks of dimness of vision at morning and
recover it after a short time. But this time vision loss is
persisting.
2) What is the hallmark of the disease?
3) Write 3 cause of vision loss.
4) In FFA, how will you differentiate active and chronic
phase?
5) Write 3 D/D?

Answer
1) Vasculitis retine/ Eale’s disease.
2) Recurrent vitreous hemorrhage is the hall
mark of this disease.
3) .
i. Vitreous Hemorrhage.
ii. Macular ischemia and
iii. traction macular detachment are associated
with poor visual outcome

Answer
4. In cases of active retinal periphlebitis,
staining of the veins can be seen in the early
venous phase with extravasations of dye in the
late phase. In the healed stage, only staining of
the vessel wall occurs without any leak in the
late venous phase.

• 5
i. Coat’s disease
ii. PDR
iii. Sickle cell retinopathy
iv. Syphilitic neuroretinitis.
(SOURCE: PAHWA : 78)

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Question
1. What are the 2 positive finding in this picture? =2
2. How many area will be non perfuse before develop
this feature? =1
3. What is your diagnosis? =2
4. What other 2 features you may get in this stage?=2
5. What other general and ocular investigation will you
perform?=2
6. If you do FFA what positive finding will you get in late
phase?=1

Answer
1= 2
i. NVD.
ii. Dot and blot hemorrhage
2. More than one quarter of the retina to be non-
perfuse before develop this feature. =1
3. PDR= 2
4. NVE, New vessels in the iris = 2
5. RBS. Glycosylated Hb OCT. FFA.= 2
6. hyperfluorescence during the later stages =1

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Question
• A patient with sudden onset of severe headache, 6th
nerve palsy, and a bitemporal visual field defect.
1) The most likely diagnosis is?
2) Write 2 D/D.
3) Mention one investigation
4) Is this a medical emergency?

Answer
1) pituitary apoplexy
2) .
i. ruptured ophthalmic artery aneurysm
ii. meningeal carcinomatosis
iii. multiple sclerosis.
3) MRI
4) Yes

• Source: AAO Volume = 5. Page = 162,
163, 164. 346. 347

Explanation
• Sudden loss of vision, headache, and ocular motor
nerve palsies occur with rapid expansion of a
pituitary tumor into the suprasellar and cavernous
sinus regions. Prompt neuroimaging and emergency
management are essential in these cases.

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• This 75 year-old man presented to the eye casualty with a one
week history of distorted left vision. His visual acuity was
6/18 in the left eye with the above posterior segment
appearance. He had no history of hypertension or diabetes
mellitus.
1) What is the most likely diagnosis? =2
2) What is the main cause of vision loss in this patient.=3
3) In some other disease vision may reduced in the same
manner. Mention 3.
4) What are the risk factors of this condition? Mention 4.= 2

• 1 ARMD
• 2 SRNVM

1) Age is the major risk factor.
2) Race. Late ARM is more common in Caucasians
than other races, despite a similar prevalence of
early ARMD.
3) Heredity. Family history is important.
4) Smoking

5. Hypertension and other cardiovascular risk
factors are likely to be associated.
6. Dietary factors. High fat intake and obesity may
promote AMD, with high antioxidant intake
having a protective effect in some groups (see
below).
7. Other factors such as cataract surgery, blue iris
colour, high sunlight exposure, and female gender
are suspected, but their influence remains less
certain.

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Scenario
A man 35 year old executive of a multinational
company. Normotensive, non smoker & non
diabetic, came to with the complaints of
sudden dimness of vision right eye.
O/E VAR = 6/12 improves with +1.00 Dsph
VAL 6/6 unaided.
Pupillary reaction normal.
Slit lamp examination= NAD.

Question
1) What may be the diagnosis?
2) What finding will you get by ophthalmoscope
exam? Mention 2
3) What is the natural course of the disease?
a)
b)
c)

Answer
1) CSCR
2)
A round or oval detachment of the sensory retina is present at the
macula
• The subretinal fluid may be clear (particularly in early
lesions), turbid or fibrinous, and precipitates may be present
on the posterior retinal surface.
• One or more abnormal depigmented RPE foci
(sometimes small PEDs) of variable size may be visible
within the neurosensory detachment.
• Small patches of RPE atrophy and hyperplasia
elsewhere in the posterior pole may indicate the site of
previous lesions.7/17/2014 106anjumk38dmc@gmail.com

Answer
• 3)
• a) Spontaneous resolution.
• b) Chronic
• c) Bullous CSCR
(Source Kanski)

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The imaging is carried out on a patient who
suffers from branch retinal vein occlusion.

Answer the following questions:
1) What is this imaging technique?
2) What is the diagnosis (F stands for
fovea)?
3) Write 3 predisposing factors of CRVO
4) Write 2 vision threatening complications
7/17/2014 anjumk38dmc@gmail.com 110

Answer:
• 1) OCT================= 2
• 2) CMO=================2
• 3)
a) Age ==================1
b)Hypertension ============1
c)Hyperlipidaemia.==========1
d) Diabetes mellitus =========1
e) Oral contraceptive pill.===== 0.5
f) Raised intraocular pressure == 0.5
g) Smoking. ============== 0.5

Answer
• 4)
• a) Chronic macular edema ======= 1.5
• b) Neovascularization.========== 1.5

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OSPE
Scenario: This is a fundus photograph of 60 – year
old male with blurring of vision.
Please observe the photograph and answer the
following questions.
Q . 1
Write 4 important positive findings in this
photograph.
a .
b.
c .
d.

OSPE
Question 2. Mention 3 differential diagnosis.
a) .
b) .
c) .

OSPE
Question 3.
• Write 1) 2 systemic & 2) 2 ocular
investigations to confirm the diagnosis
• 1)
• a.
• b.
• 2)
• a
• b

Marking Scheme
Question: 1. (any 4)
Write 4 important clinical findings,
a . New vessels at elsewhere (NVE) --- 1
b. Multiple dot-blot hemorrhage -------1
c . Multiple hard exudate-----------------1
d) Laser scars ------------------------------1
e. Arterial attenuation --------------------0.5

OSPE
• Question: 2. Mention 3 D/D. ( 1 X 3 =3)
• a. Proliferative diabetic retinopathy (PDR)
• b. Pre- Proliferative diabetic retinopathy
(PPDR)
• c. Central vein occlusion (CRVO)

OSPE
Question 3.
• Write 2 systemic & 2 ocular investigations to
confirm the diagnosis
• 1) ( 0.5x2= 1)
• a) Blood Sugar. Fasting & 2 hrs after breakfast/
GTT.
• b) HbA1C
• 2) (1x2 = 2)
a) Fundus Fluorescence angiography (FFA)
b) Optical Coherence Tomography. (OCT)7/17/2014 120anjumk38dmc@gmail.com

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Question
• This is a fundus photograph of 65 year- old
lady, who is suffering from central visual loss
for last few days,
• Q 1. What is your diagnosis?
• Q 2. What are the cause? Mention 3
• Q 3. Name 4 lesion with similar appearance
• Q 4 What are the investigation you do?

Answer
1) Macular Hole.
2) .
i. Idiopathic
ii. High Myopia
iii. Blunt Ocular trauma.
3)

Answer
3) Lesions with a similar appearance
a) Pseudo hole in a macular epiretinal membrane.
b) Lamellar hole resulting from an abortive process of
macular hole formation or in long-standing severe
CMO.
c) Foveal pseudo cyst, typically idiopathic; in at least
some patients may correspond to stage 1 macular hole.
d) Vitreomacular traction syndrome.
e) Solar retinopathy.
f) Macular micromole

Answer
i. The Watzke–Allen test.
ii. OCT.
iii. FA
iv. Amsler grid
(Source: Jack J Kanski)

GOOD LUCK7/17/2014 127anjumk38dmc@gmail.com

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